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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203506
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:36:57 PM

Document Has Been Signed on 02/25/2025 03:36 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SVS CLOVIS ADULT DAY PROGRAMFACILITY NUMBER:
107203506
ADMINISTRATOR/
DIRECTOR:		BANUELOS, CHERIFACILITY TYPE:
775
ADDRESS:155 PARK CREEK DRIVE, #101TELEPHONE:
(559) 323-0537
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 90CENSUS: 80DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:56 AM
MET WITH:Program Director: Alex WilliamsTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 2/25/25, Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and met with Program Director (PD) Alex Williams. Some clients were participating in Community Integration and some were programming in the facility during the inspection. LPA conducted facility tour with PD.

LPA toured the facility. All passageways and exits were clear and free from obstruction. Facility was at


comfortable temperature maintained at 70 degrees F. The Day Program has 9 classrooms. LPA toured lab
room, library, art room, media room, gym, music room, computer club, game room and kitchen. All classrooms and activity areas were clean and odor free. Clients bring their lunches. Kitchen is for small cooking experiences and appeared clean. Food was observed to be stored in refrigerator and freezer. Client’s bathrooms were observed clean, and fixtures were functioning properly. Water temperature was measured in all 6 bathrooms. 4 out of 6 bathrooms water temperature measured at a range of 103.4 to 104 degrees F. Cleaning supplies observed stored and locked in supply closet. Facility quiet room and changing room was toured. Fire extinguisher observed throughout the facility with a serviced date 1/6/2025. Carbon monoxide and smoke detectors were tested and observed to be operational. Fire drill last completed 11/12/24. Samples of client and staff files were reviewed to have all required documents. First Aid/CPR, fingerprint clear and associated to the facility.

The following deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SVS CLOVIS ADULT DAY PROGRAM
FACILITY NUMBER: 107203506
VISIT DATE: 02/25/2025
NARRATIVE
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Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 3/11/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A)

A copy of this report and appeal rights was submitted to PD whose signature confirms receipt of the report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 03:36 PM - It Cannot Be Edited


Created By: Jacques Leffall On 02/25/2025 at 03:04 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SVS CLOVIS ADULT DAY PROGRAM
FACILITY NUMBER: 107203506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in 4 out of 6 bathroom faucets measured under the required regulation of 105 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Licensee agrees to have maintenance repair to adjust the water temperature to meet the required regulation. Licensee agrees to submit documentation of adjusted water temperature meeting the required regulation to CCLD by POC due date.
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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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