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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002436
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:14:55 PM

Document Has Been Signed on 05/29/2024 02:14 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 - RAWSON HOMEFACILITY NUMBER:
525002436
ADMINISTRATOR/
DIRECTOR:		FULK, ERICFACILITY TYPE:
735
ADDRESS:10770 RAWSON RDTELEPHONE:
(530) 527-7987
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 4DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Velvet Paterson - Program DirectorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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05/29/2024 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Velvet Peterson Program Director and explained the purpose of the visit.

LPA Knight and the program director toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a locked cabinet.

Fire extinguishers fully charged and were inspected in March 2024. Smoke detectors are all operational. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. The facility has been conducting fire drills and emergency disaster drills monthly.

A deficiency is being cited as a result of today’s inspection and is documented on the attached LIC809-D. LPA observed 3 inch hole in bathroom wall that needs to be repaired. LPA observed Client room 1 needs door to be replaced due to damage. LPA observed Client room 2 door is missing and the door needs to be replaced.



Exit interview conducted and copy of report was provided to Velvet Peterson.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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Document Has Been Signed on 05/29/2024 02:14 PM - It Cannot Be Edited


Created By: Rebecca Knight On 05/29/2024 at 01:39 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 - RAWSON HOME
FACILITY NUMBER: 525002436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

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 observation, the licensee did not comply with the section cited above in 2 of 4 client doors and 1 of 2 bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee agrees to repair 3 inch hole in bathroom wall. Licensee agrees to replace doors on Client room 1 and client room 2. Licensee shall submit photographs of completed repairs to LPA as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
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