525002278-10-24-2025-59-AS-SBEN-DMRVDK-20251024162053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525002278
Report Date: 10/24/2025
Date Signed: 10/24/2025 04:21:03 PM

Document Has Been Signed on 10/24/2025 04:21 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 - MCCOY HOME		FACILITY NUMBER:	525002278
ADMINISTRATOR/ DIRECTOR:	OWENS, JESSICA		FACILITY TYPE:	735
ADDRESS:	16993 MCCOY RD		TELEPHONE:	(530) 529-4771
CITY:	COTTONWOOD	STATE: CA	ZIP CODE:	96022
CAPACITY: 4		CENSUS: 4	DATE:	10/24/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:45 PM
MET WITH:	Administrator Tonya Foster		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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On 1-24-25 at 3:45pm Licensing Program Analyst LPA Sarah Benson arrived to perform a case management concerning a SOC 341 reported by the facility staff on 9-30-25. It was reported that C1 made sexual harassment allegations about staff S2 member. It was reported C1 often states a male peer, instructor or staff member is beautiful and becomes infatuated, excited and over stimulated which results in physical aggression and property destruction. It was reported C1 has become fixated on peers and staff he found attractive. It was reported C1 regularly visits his physician that help with his behaviors and a few days before the visits behaviors are exaggerated and makes sexually allegations about staff. It was reported just before his doctor visit is due the client will also start talking of previous abuse. It was reported we have a two person staff at all times because of past behaviors and sexual type allegations. LPA Benson has interviewed the client and staff members. During the investigation process, it was reported there has been a history with the client making untruthful allegations. C1 has a history of making these allegations with different individuals.

Based on investigation observations, record review(s) and interviews which were conducted no decencies are being cited.

The facility has taken the following steps to insure the health and safety of residents in care.

1.The client will have his medication re-evaluated.

2. Will relocate the staff one S1.

3. Staff will seek a maladaptive specialist for clients behaviors.

Exit interview conducted, a copy of the report provided to administrator.

NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Sarah Benson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025

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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