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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002667
Report Date: 04/08/2024
Date Signed: 04/09/2024 03:26:23 PM

Document Has Been Signed on 04/09/2024 03:26 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-OAK CREEKFACILITY NUMBER:
525002667
ADMINISTRATOR/
DIRECTOR:		NUNEZ, MARETTAFACILITY TYPE:
735
ADDRESS:18850 OAK CREEK COURTTELEPHONE:
(530) 527-7987
CITY:COTTONWOODSTATE: CAZIP CODE:
96022
CAPACITY: 4CENSUS: 4DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jessica Owens AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 04/08/2024 02:00 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Jessica Owens with a pending status on administrator site. Mareta T Nunez is the administrator on file (cert #6051777735 exp:11-17-25) LPA Benson explained the purpose of the visit. Administrator certificate is current.

LPA Benson and administrator 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. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Benson was unable to review Staff files as they were unavailable. Resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.



The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. LPA was unable to verify all employees requiring background checks were cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility.
No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 1-15-24, the facility has been conducting drills every 3 months.LPA Benson was unable to complete yearly annual inspection as no staff files were available in a timely manner. LPA Benson will return to complete inspection. Exit interview was conducted and a copy given to Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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