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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002435
Report Date: 05/31/2022
Date Signed: 05/31/2022 01:15:05 PM

Document Has Been Signed on 05/31/2022 01:15 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:NORTH VALLEY SERVICES - LUCKNOW HOMEFACILITY NUMBER:
525002435
ADMINISTRATOR:PETERSON, VELVETFACILITY TYPE:
735
ADDRESS:502 LUCKNOW AVETELEPHONE:
(530) 527-0407
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 3CENSUS: DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Velvet Peterson - administratorTIME COMPLETED:
02:00 PM
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05/31/2022 1:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with administrator Velvet Peterson and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask, gloves.

LPA Knight and Ms. Peterson toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, two (2) bathrooms, kitchen, garage/office, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and the administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was given to administrator Velvet Peterson.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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