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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455920186
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:31:06 AM

Document Has Been Signed on 07/16/2024 11:31 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 #7FACILITY NUMBER:
455920186
ADMINISTRATOR/
DIRECTOR:		DORE, SHANNONFACILITY TYPE:
735
ADDRESS:1786 STERLING DRIVETELEPHONE:
(530) 768-1582
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 0DATE:
07/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensees, Debbie Larmour & Patti Moore, Administrator, Shannon Dore, HR Director, Sarah Holleman, Manager, Daniell PageTIME VISIT/
INSPECTION COMPLETED:
11:30 PM
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On July 16, 2024 at approximately 10:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at Mid Valley Providers #7 for the purpose of conducting a Pre-Licensing inspection. LPA was greeted at the door by Licensee, Debbie Larmour and was granted access into the facility. Also participating in this Pre Licensing inspection are, Administrator, Shannon Dore, HR Director, Sarah Holleman, Manager, Daniell Page. The Fire Clearance was granted for 4 Ambulatory clients with 0 Non-Ambulatory and 0 Bedridden clients. Administrators Certificate (Administrator Certificate #: 7005190735 was issued on 08/11/2022 with an expiration 08/11/2024) was reviewed by the LPA during the Pre-Licensing Inspection and found to be valid and appropriate. A copy of the Administrators First Aid Certificate and CPR was valid and expires on January 2025.

LPA, Licensee and Prospective Administrator toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. Sample Menu was observed. Fire Extinguisher was last inspected on June 2024. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the Pre-Licensing inspection. The pull fire alarm was just installed. Hot water temperature measured at 110 degrees in 2 of 2 clients bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Client records, personnel Records, medication will be locked and in separate cabinets, toxins are kept locked and inaccessible to clients in care. Facility will be bringing the facility first aid kit upon move in. There is an outdoor space for activities with a shaded area. Garage was inspected and found to be appropriate. During the Pre-Licensing inspection, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 + or any infectious diseases in the facility. Emergency Disaster plan was discussed with the Administrator and the Licensee. All staff will be trained in the Emergency Disaster plan. Emergency Disaster was last conducted on July 15, 2024.

(Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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 #7
FACILITY NUMBER: 455920186
VISIT DATE: 07/16/2024
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LPA was made aware that the Licensee also operates another Adult Residential Facility in another County. Component III was waived due to already operating a Community Care Facility.

Exit interview was conducted, and a copy of this report was emailed to the Administrator due to printer issues. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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