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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002208
Report Date: 08/23/2023
Date Signed: 08/23/2023 01:49:44 PM

Document Has Been Signed on 08/23/2023 01:49 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 - A/C WESTFACILITY NUMBER:
525002208
ADMINISTRATOR:COX, CONNIEFACILITY TYPE:
775
ADDRESS:12097 HWY 99 WTELEPHONE:
(530) 527-9602
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 60CENSUS: 15DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Connie Cox - administratorTIME COMPLETED:
02:00 PM
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08/23/2023 12:15 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Connie Cox and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients who attend program. Areas toured include but are not limited to common areas, bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared.

There is a schedule of recreational activities planned for the clients and clients are given the choice to go out in the community or stay at program each day.

The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored properly. Fire extinguishers fully charged and were inspected in August 2023. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted in July 2023 which was a fire drill, the facility has been conducting fire drills monthly. Facility is conducting emergency disaster drills monthly.

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was provided to administrator Connie Cox.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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