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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001690
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:28:05 PM

Document Has Been Signed on 09/20/2024 02:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:INTERMOUNTAIN DISABILITY SERVICESFACILITY NUMBER:
455001690
ADMINISTRATOR/
DIRECTOR:
JOHNSON, BRENDAFACILITY TYPE:
775
ADDRESS:37009 HWY 299ETELEPHONE:
(530) 335-2833
CITY:BURNEYSTATE: CAZIP CODE:
96013
CAPACITY: 30CENSUS: 5DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Glenna Miller AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 9/20/2024 at 11:30 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Glenna Miller and explained the purpose of the visit.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed.



The common area was clean and in good repair. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly.

First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 9-5-24, the facility has been conducting drills every month.

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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