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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002110
Report Date: 08/19/2021
Date Signed: 08/19/2021 02:44:57 PM

Document Has Been Signed on 08/19/2021 02:44 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MID VALLEY PROVIDERS #3FACILITY NUMBER:
455002110
ADMINISTRATOR:LARMOUR, DEBBIEFACILITY TYPE:
735
ADDRESS:1688 STERLING DRIVETELEPHONE:
(530) 605-3061
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 4DATE:
08/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leonard Warmington; House ManagerTIME COMPLETED:
03:00 PM
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On 8/19/21 at 1 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigations visit regarding the above allegations and met with Leonard Warmington. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask and gloves. Additionally, LPA was screened by staff. All interviews and file reviews were conduct in the backyard patio of the facility where more than 6 feet of social distancing was implemented.

On 8/19/21 at 1:30 PM, LPA Cheng interviewed C1, S1, and S2.

On 8/19/21 at 2PM, LPA requested to see C1's IPP, physician's report, and C1's Behavioral Action Plan.

LPA determined that C1 had left the facility unassisted on 8/15/21 by exiting the via garage side door; however, facility has ongoing preventative measures in place to ensure supervision to reduce the frequencies of these incidents and an active behavioral plan with C1. C1 was located in under 15 minutes and was redirected back to the facility without injuries. Facility had sufficient supervision at the time of the incident, ongoing behavioral plan, preventative measures, and responded within a timely manner. C1 understood that his actions were wrong and that the facility is there to assist C1 at all times.

No deficiencies observed. Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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