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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002542
Report Date: 07/17/2023
Date Signed: 07/20/2023 10:49:08 AM

Document Has Been Signed on 07/20/2023 10:49 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 #6FACILITY NUMBER:
455002542
ADMINISTRATOR:DORE, SHANNONFACILITY TYPE:
735
ADDRESS:2521 WYNDHAM LANE #BTELEPHONE:
(530) 221-1551
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 3CENSUS: 3DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Manager- Sean BellingerTIME COMPLETED:
11:45 AM
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An annual inspection was conducted at this facility on 07/17/2023. At the time of the visit, the report was generated on the wrong facility. This report reflects the visit conducted on 07/17/2023.

On 07/17/2023, Licensing Program Analyst (LPA) Jaynae Boyles and Sarah Benson, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Manager Sean Bellinger and explained the purpose of the visit.

LPA's Boyles, Benson and Facility Manager toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, shed, and common restrooms. LPA's observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary non-skid flooring , paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 116 F. LPA's observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of three (3) residents' files and three (3) staff files.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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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