<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002436
Report Date: 06/16/2022
Date Signed: 06/16/2022 01:34:15 PM

Document Has Been Signed on 06/16/2022 01:34 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 - RAWSON HOMEFACILITY NUMBER:
525002436
ADMINISTRATOR:BURNHAM, CATHERINEFACILITY TYPE:
735
ADDRESS:10770 RAWSON RDTELEPHONE:
(530) 527-7987
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cao Buck -DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
06/16/2022 1:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the administrative office and met with Director Cao Buck. Prior to initiating the visit, 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: N95 Mask, gloves. The purpose of this visit was to conduct a case management inspection to confirm that an excluded staff was not present at or working in any facilities licensed by North Valley Services.

The Order To Individual of Immediate Exclusion letter was issued on Jun 2, 2022 to Staff 1 (S1). S1 was associated to the following facilities:


NORTH VALLEY SERVICES - RAWSON HOME
NORTH VALLEY SERVICES - SPECIALIZED RES SERVICES
GILMORE RANCH HOME
NORTH VALLEY SERVICES - LUCKNOW HOME

LPA spoke to director and explained the "Immediate Exclusion" notice indicating that S1 cannot be allowed to work, be present and/or live in a CCL licensed facility and have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Director Cao Buck indicated they understood the notice and confirmed that S1 was officially terminated from employment on 9/18/2020.

Director agrees to submit signed letter to LPA Knight by close of business 06/16/2022 that states that S1 is no longer employed by the agency.

Exit interview completed. Copy of report was emailed to director Cao Buck.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1