<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525000804
Report Date: 11/18/2022
Date Signed: 11/18/2022 11:07:20 AM

Document Has Been Signed on 11/18/2022 11:07 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:NORTH VALLEY SERVICES - BEHAVIOR MANAGEMENT PGRMFACILITY NUMBER:
525000804
ADMINISTRATOR:CHAVEZ, ESPERANZAFACILITY TYPE:
775
ADDRESS:13315 BAKER RDTELEPHONE:
(530) 528-1083
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 80CENSUS: 38DATE:
11/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Esperenanza ChavezTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hiratsuka, conducted this unannounced case management visit. LPA wore a surgical mask during visit and observed staff wearing surgical masks.

This is in response to an incident report submitted by this facility on 10/25/2022, for an incident that occurred on 10/24/2022. A client had a major behavior that required restraints. The client did not suffer any injuries and also has not suffered any ill-effects from the event. The facility staff did an updated individual service plan for the client. The other client involved did not suffer any ill-effects. The staff involved did not have any injuries and the incident was reviewed and discussed with all staff.

Based on the interview and review of the incident report the facility did not violate any regulations.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1