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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002667
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:27:15 PM

Document Has Been Signed on 04/09/2024 03:27 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:
04/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Jessica Owens AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:27 PM
NARRATIVE
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On 4-8-24 Licensing Program Analyst LPA Sarah Benson arrived at the facility at 2:00PM to conduct the required-1 Year inspection. The staff files are kept at the main office. Staff requested the files for LPA Benson file review. The staff with files arrived at 4:26PM. LPA Benson stated it was too late to complete the annual today. LPA will complete the annual at a later date. Jessica Owens requested changing administrator from Mareta T Nunez to Jessica Owens. LPA Benson emailed Jessica Owens with information required to change administrator status.

LPA Benson arrived at 3:00PM on 4-9-24 to complete the Required-1 Year inspection. Staff files were reviewed.

Exit interview was conducted The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, a copy of the report, and appeal rights provided to administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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 04/09/2024 03:27 PM - It Cannot Be Edited


Created By: Sarah Benson On 04/09/2024 at 08:34 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-OAK CREEK
FACILITY NUMBER: 525002667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2024
Section Cited
CCR
87412(a)(11)(a)

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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: ...
This requirement is not met as evidenced by:
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Staff will notify office or administrator of LPA requesting staff files upon arrival of LPA.
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The staff files were not available for LPA's review in a timely matter.
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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:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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