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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203506
Report Date: 02/20/2025
Date Signed: 02/20/2025 10:17:51 AM

Document Has Been Signed on 02/20/2025 10:17 AM - 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:
02/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Program Director: Alex WilliamsTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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On 2/20/25, Licensing Program Analyst (LPA) J. Leffall conducted a case management visit to follow up and confirm details of an incident report that was received by the Department. The incident occurred on 1/15/25, in which Client’s Health and Safety were at risk from a vehicle accident. Staff was transporting clients during community integration when the accident occurred. An internal investigation was conducted, and it was concluded that Staff (S1) was at fault in the vehicle accident.

Per Internal Investigation findings, S1 was issued a T252 - Notice of Driving Probation that requires S1 to be on a driving probation that ends on 8/13/25. S1 has signed an acknowledge agreement that states, “I understand the importance of safe driving and am willing to follow all driving safety rules during my probation as an SVS driver and thereafter if I am maintained as an SVS driver.” Both investigative findings and Police Report forms were submitted to CCLD.

A citation is issued on the attached 809-D regarding client’s Health and Safety.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 02/20/2025 10:17 AM - It Cannot Be Edited


Created By: Jacques Leffall On 02/20/2025 at 08:54 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
, 1314 E SHAW AVE
FRESNO, CA 93710

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
82065(f)(3)

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f) All personnel shall be given on-the-job training or shall have related experience providing knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

(3) Provision of client care and supervision, including communication.
This requirement was not met as evidenced by the facility’s report and investigation that staff did not maintain safety to clients, which poses an immediate health, safety, and personal rights risk.
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Licensee agrees to have staff complete Defensive Driving Techniques training and place staff on a driving probation that prohibits staff’s driving privileges to transport clients through 8/13/25.
***POC cleared during visit

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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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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