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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002436
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:42:28 PM

Document Has Been Signed on 08/20/2024 03:42 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:
08/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Leka Nunez - administratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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08/20/2024 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Leka Nunez. Today’s visit is regarding an incident that occurred on 08/04/2024 and was reported to licensing on 08/06/2024.

It was reported that on 08/04/2024 Client 1 (C1) eloped out the home's front gate after being told they could not have an energy drink since they had received their earned energy drink as stated in their plan. Staff followed C1 and called on-call for backup. The on-call told the staff they were on the way and instructed the staff to call the Sheriff if C1 trespassed onto a neighbor's property. C1 trespassed onto a neighbor’s property. The staff notified the sheriff’s office, and the Sheriff referred staff to the mobile crisis unit line, but the crisis line would not respond. C1 then attempted to open the front window of the neighbor’s house. The staff continued to encourage C1 to return to the vehicle. C1 could not get into the neighbor’s house and walked around the building once before returning to the road. C1 walked 100 yards down the road when a car driving down the road pulled up alongside C1 and C1 got into the passenger seat of the person's vehicle. The staff member caught up with the vehicle from behind and started honking after it started driving for a little while and asked C1 to exit the vehicle. C1 exited the vehicle then immediately picked up rocks off the shoulder of the road and started throwing them at the company vehicle. Staff got in the vehicle to drive it away to avoid damages. At this time, the administrator arrived, and crisis communicated with C1 and managed to get C1 to agree to get into the vehicle under their own will. C1 got into the vehicle on his own and was driven home.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 - RAWSON HOME
FACILITY NUMBER: 525002436
VISIT DATE: 08/20/2024
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During the course of the investigation, it was determined that C1 has been exhibiting this behavior consistently over time and has eloped numerous times from the facility. The facility is located on a very busy and dangerous road. C1 got into an unknown person's vehicle which poses an added level of danger. The facility staff have been trying to help to manage C1’s behavior by following C1 when they elope from the facility and trying to keep C1 safe. C1 has trespassed onto neighbor’s properties and been warned and threatened by neighbors as a result. This puts C1 and staff in a dangerous position. Administrator states that C1 has an appointment with their physician to possibly change medications to help with the behavior. LPA is requesting that the licensee increase staffing for C1 in order to keep C1 safe, and to also update C1's Needs & Services plan and Physicians Report to include any recommendations made by C1's physician to help manage these behaviors.


A deficiency was cited as a result of today’s visit and is documented on the attached LIC809-D. Exit interview conducted and a copy of the report was provided to Leka Nunez.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2024 03:42 PM - It Cannot Be Edited


Created By: Rebecca Knight On 08/20/2024 at 02:44 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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2024
Section Cited
CCR
85078(a(1)

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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 increase staffing for C1 in order to keep C1 safe. In addition licensee will update C1's Needs & Services plan and Physicians Report to include any recommendations made by C1's physician to help manage these behaviors to ensure C1 does not elope from the facility. Licensee will provide evidence to LPA showing increased staffing has been arranged for C1 and updated Nees & Services plan and Physicians Report as proof of correction.
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Based on LPA interviews the licensee failed to manage a re-occurring behavior of elopement from the facility by C1 which placed the client in an extremely dangerous situation. This poses an immediate risk to clients in care.
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POC due 09/03/2024.

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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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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