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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002435
Report Date: 05/14/2024
Date Signed: 05/14/2024 12:31:10 PM

Document Has Been Signed on 05/14/2024 12:31 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 - LUCKNOW HOMEFACILITY NUMBER:
525002435
ADMINISTRATOR/
DIRECTOR:		FOSTER, TONYAFACILITY TYPE:
735
ADDRESS:502 LUCKNOW AVETELEPHONE:
(530) 527-0407
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 3CENSUS: 2DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Tonya Foster - administratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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05/14/2024 10:30 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 6066804735 exp.07/19/2025 and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to three (3) 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. Administrator certificate is current. Medications were reviewed.

Clients participate in activities of their choice. 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. There are no pools/bodies of water are on premises. Last disaster drill was conducted in April 2024, which was a fallen aircraft drill, the facility has been conducting various types of drills monthly.

Continued on LIC809-C
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - LUCKNOW HOME
FACILITY NUMBER: 525002435
VISIT DATE: 05/14/2024
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LPA requested the following documents that need to be updated in the facility file:
LIC500 Personnel Report
LIC308 Designation of Facility Responsibility

The following deficiencies are being cited as a result of today’s inspection and are documented on the LIC809-D.

LPA observed the finishing on the decks and ramps in front of and behind the home need to be painted or stained.

LPA observed the front door needs to be replaced due to significant damage and wear.

LPA observed the back door needs to be replaced due to significant damage and wear.

LPA observed the toilet in bathroom #1 needs to be repaired or replaced.

Exit interview conducted and copy of report was provided to administrator Tonya Foster.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2024 12:31 PM - It Cannot Be Edited


Created By: Rebecca Knight On 05/14/2024 at 12:13 PM
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 - LUCKNOW HOME
FACILITY NUMBER: 525002435

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. The finishing on the decks and ramps in front of and behind the home need to be painted or stained. Front door needs to be replaced due to significant damage and wear. Back door needs to be replaced due to significant damage and wear.
POC Due Date: 06/04/2024
Plan of Correction
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Licensee agrees to complete repairs / replacement of the items listed and submit photographs of the repairs as proof of correction.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 of 2 toilets which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2024
Plan of Correction
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Licensee agrees to complete repairs / replacement of the items listed and submit photographs of the repairs as proof of correction.
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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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