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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002278
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:08:48 AM

Document Has Been Signed on 08/22/2023 11:08 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 - MCCOY HOMEFACILITY NUMBER:
525002278
ADMINISTRATOR:CONTRERAS, EZEKIELFACILITY TYPE:
735
ADDRESS:16993 MCCOY RDTELEPHONE:
(530) 529-4771
CITY:COTTONWOODSTATE: CAZIP CODE:
96022
CAPACITY: 4CENSUS: 4DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tanya Foster - administratorTIME COMPLETED:
11:30 PM
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05/17/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Tanya Foster and staff Jessica Owens and explained the purpose of the visit.

LPA Knight and staff toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, common areas, two (2) 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. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in April 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 an explosion evacuation drill, the facility has been conducting fire drills monthly.

A deficiency is being cited as a result of today’s inspection and is explained on the attached LIC9099-D.

Exit interview conducted and copy of report was provided to Director of Residential Services Velvet Peterson.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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Document Has Been Signed on 08/22/2023 11:08 AM - It Cannot Be Edited


Created By: Rebecca Knight On 08/22/2023 at 10:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NORTH VALLEY SERVICES - MCCOY HOME
FACILITY NUMBER: 525002278

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in one out of two staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Licensee will arrange for the staff person to renew their first aid certificate. Licensee shall send proof of correction to LPA by 09/05/2023. Licensee shall contact LPA if a time extension is required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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