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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002435
Report Date: 11/30/2023
Date Signed: 11/30/2023 11:28:07 AM

Document Has Been Signed on 11/30/2023 11:28 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 - LUCKNOW HOMEFACILITY NUMBER:
525002435
ADMINISTRATOR:FOSTER, TONYAFACILITY TYPE:
735
ADDRESS:502 LUCKNOW AVETELEPHONE:
(530) 527-0407
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 3CENSUS: 3DATE:
11/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tonya Foster - administratorTIME COMPLETED:
11:45 AM
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11/30/2023 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Tonya Foster. Today’s visit is regarding an incident that occurred on 11/20/2023 and was reported to licensing the same day.

It was reported that on 11/20/2023 Client 1 (C1) was in their room watching television and went to ask Staff 1 (S1) for a cigarette. S1 grabbed the cigarette and lit it for C1 outside. While C1 was sitting outside they eloped past the boundaries of the facility. S1 followed C1 but stayed on the facility property and called the on-call staff. The staff was able to maintain visual of C1 until C1 walked down the road towards a curve. The On-call Staff 2 (S2) located C1 very soon after. S2 observed a man with a gun in one hand and a flashlight in the other stating that he was a police officer and he was going to shoot C1 because they were breaking into the man’s house. S2 quickly got C1 into the vehicle and shut the door. The man continued to yell at C1 while the S2 apologized for the disturbance. C1 was taken home and was stable for the remainder of the night.

During the course of the investigation, it was learned that C1 is known to frequently elope from the facility and attempt to make contact with neighbors by knocking on doors in the early hours of the morning. The facility was issued a citation on 6/25/2021 by the department due to C1 eloping from the facility. At that time the department required the facility to increase staffing for the graveyard shift to ensure that two staff were on duty. During the current incident staff had called out and this left one staff on duty during graveyard shift which prevented staff from being able to leave the facility and follow C1 when they eloped from the facility which placed C1 in grave danger due to the response from the neighbor.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Tonya Foster.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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 11/30/2023 11:28 AM - It Cannot Be Edited


Created By: Rebecca Knight On 11/30/2023 at 11:05 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 - LUCKNOW HOME
FACILITY NUMBER: 525002435

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2023
Section Cited
CCR
85078

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85078(a)(1) Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee agrees to submit a plan to licensing which explains how they will ensure there are always 2 staff on duty during the graveyard shift.even if staff call out. Licensee will provide this plan to LPA as proof of correction.
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Based on LPA interviews the licensee failed to provide staffing necessary to ensure 1 of 1 clients did not leave the facility unassisted and unsupervised which place the client in an extremely dangerous situation. This poses an immediate risk to clients in care.
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POC due 12/14/2023.

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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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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