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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200203
Report Date: 09/19/2024
Date Signed: 09/19/2024 01:41:32 PM

Document Has Been Signed on 09/19/2024 01:41 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SOCIAL VOCATIONAL SERVICES, NEWARKFACILITY NUMBER:
019200203
ADMINISTRATOR/
DIRECTOR:		BOLIVIA, MICHELLEFACILITY TYPE:
775
ADDRESS:37400 CEDAR BLVD., SUITES A&BTELEPHONE:
(510) 797-1916
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 90CENSUS: 65DATE:
09/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Michelle BoliviaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At around 12:35pm noon, LPA conducted a case management - incident visit and met with Michelle Bolivia. .LPA explained to Bolivia the purpose of the visit. LPA is conducting this visit in regards to an incident

During the visit, LPA interviewed Client 1 (C1) in regard to the incident when C1 fell at a McDonald's and sustained bruises, abrasions and a small cut on the arm. C1 states that C1 would always bring food for lunch from the home. On the day C1 fell, C1 states that the staff asked C1 to help carry the foods for the staff and other clients back to the van.C1 states that Staff 1 (S1) was informed about the fall but C1's home staff were not informed about the incident.

LPA interviewed Client 2 (C2) who was with C1 during the incident. C2 states that C2 was with C1 all the time and did not observe C1 fall at the McDonald's. During the visit, LPA also interviewed the two staff who were with C1 and C2 and both denied seeing C1 fall or seeing anything unusual about C1.

S1, S2 and C2 all denied observing C1 fall while at McDonald's. S2 denied being informed by C1 about the fall.

There is no deficiency noted for this visit.

A copy of this report was provided to Bolivia.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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