525000804-3-3-2026-59-AS-RKNT-DRTQ8H-20260303105646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525000804
Report Date: 03/03/2026
Date Signed: 03/03/2026 10:57:16 AM

Document Has Been Signed on 03/03/2026 10:57 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:	NORTH VALLEY SERVICES - BEHAVIOR MANAGEMENT PGRM		FACILITY NUMBER:	525000804
ADMINISTRATOR/ DIRECTOR:	CHAVEZ, ESPERANZA		FACILITY TYPE:	775
ADDRESS:	13315 BAKER RD		TELEPHONE:	(530) 528-1083
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY: 80		CENSUS: 23	DATE:	03/03/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	Esperanza Chavez - administrator		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

NARRATIVE

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03/03/2026 10:20 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Esperanza Chavez. Today’s visit is regarding an incident that occurred on 02/19/2026 and was reported to licensing on 02/20/2026.

It was reported that on 02/19/2026 10:27 a.m. Staff observed C1 fall and hit the floor. Staff immediately assisted C1 by helping them sit up on the ground. While seated, staff noticed a visible bulge near C1’s shoulder, and their arm appeared to be hanging. C1 stated they could not move their arm and expressed pain. Staff immediately contacted C1’s house administrator and notified them of the incident and the need to call an ambulance due to the appearance of C1’s injury. House administrator stated they would meet the paramedics at the day program site. 10:45 a.m. – 911 was called and C1 was transported to the hospital for further medical evaluation and treatment. 12:00 p.m. The house administrator reported to the day program that C1 had a broken humerus bone.

During the course of the investigation, it was learned that C1 was wearing shoes that had very worn soles which could have contributed to the fall. LPA viewed photographs of the shoes that C1 was wearing the day of the fall and confirmed they were very worn. LPA viewed photographs that were taken directly after the fal lof the area of floor where C1 fell and it appeared to be dry. Administrator stated that no other clients fell at the day program on the day of C1’s fall. The day program had appropriate staffing ratios when the incident occurred.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to administrator Esperanza Chavez.

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Rebecca Knight
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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