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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002110
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:44:30 AM

Document Has Been Signed on 06/12/2024 11:44 AM - 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:MID VALLEY PROVIDERS #3FACILITY NUMBER:
455002110
ADMINISTRATOR/
DIRECTOR:		LARMOUR, DEBBIEFACILITY TYPE:
735
ADDRESS:1688 STERLING DRIVETELEPHONE:
(530) 605-3061
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: DATE:
06/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Shannon DoreTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 06/12/2024, Licensing Program Analyst (LPA) Ivan Avila arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the Department received via fax on 05/28/2024. LPA met with Administrator Shannon Dore and explained the purpose of the visit.

The incident occurred on 05/26/2024 at approximately 6:30 PM when C1 eloped over the back fence of the facility into a wooded area. C1 was dressed in a full camouflage ghillie suit which is used by the military for hiding out in foliage. Facility staff could not locate C1 for 30 minutes until the Redding Police Department (RPD) received a disturbance call from a neighbor stating that there was a strange man in their backyard. The neighbor told police that the man had threatened her children that were playing in the wooded area. C1 had reportedly threatened the children with bodily harm, stating he had a gun and was going to shoot them. RPD had C1 at gun point until facility staff arrived and de-escalated the situation and C1 was escorted back to the facility.

During the investigation, it was learned that C1 is known to frequently elope from the facility and attempt to make contact with neighbors and looking through windows. LPA Avila received a call from a neighbor on 05/29/2024 stating that her daughter found a man in a ghillie suit hiding behind her fence. The neighbor’s daughter is an Iraq veteran who was triggered by this incident and drew a weapon on C1 after he was non-responsive. The daughter filmed the encounter and sent the video to LPA Avila for review. LPA Avila reviewed the video and it showed C1 next to the neighbor’s fence wearing a ghillie suite while the daughter was asking C1 to leave her property, or she was going to call the police.

Continued on LIC 809-C
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MID VALLEY PROVIDERS #3
FACILITY NUMBER: 455002110
VISIT DATE: 06/12/2024
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LPA Avila received a separate SIR stating C1 eloped on 6/10/2024 at approximately 8:45 AM and was later dropped off by RPD for trespassing on a construction site. RPD dropped off C1 at the Mid Valley Provides main office where staff escorted C1 back to the facility.

As a result of the incidents, a deficiency is being cited per California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency is documented on the LIC 809-D page.

Exit interview conducted, a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2024 11:44 AM - It Cannot Be Edited


Created By: Ivan Avila On 06/12/2024 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MID VALLEY PROVIDERS #3
FACILITY NUMBER: 455002110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
CCR
85065(b)

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85065(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
This requirement is not met as evidence by:
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Facility will complete a statement of understanding regarding regulation 85065(b). Facility will submit statement of understanding to LPA by POC due date of 06/14/2024.
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Based on file review and interview, the Licensee did not comply in the section cited above as the client eloped the facility and did not ensure the care and supervision to meet client needs, which poses an immediate health, safety, and personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Ivan Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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