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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525000804
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:49:32 PM

Document Has Been Signed on 03/05/2024 12:49 PM - 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 PGRMFACILITY NUMBER:
525000804
ADMINISTRATOR:CHAVEZ, ESPERANZAFACILITY TYPE:
775
ADDRESS:13315 BAKER RDTELEPHONE:
(530) 528-1083
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 80CENSUS: DATE:
03/05/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Esperanza Chavez - administratorTIME COMPLETED:
01:00 PM
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03/05/2024 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Esperanza Chavez The purpose of this visit was to conduct interviews related to an incident that occurred at another facility.

LPA interviewed the administrator and 1 client during the visit.

No deficiencies cited. Exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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