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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700054
Report Date: 02/07/2025
Date Signed: 02/07/2025 03:34:53 PM

Document Has Been Signed on 02/07/2025 03:34 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:ADULT VOCATIONAL SERVICES INCFACILITY NUMBER:
312700054
ADMINISTRATOR/
DIRECTOR:		SUH, SEANFACILITY TYPE:
775
ADDRESS:3845 ATHERTON RD #7TELEPHONE:
(916) 204-5726
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 45CENSUS: DATE:
02/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Nati MaugaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 2/7/2025 LPA Tryon visited the program to discuss an incident that happened on 1/17/2025. On that day the program had several clients out in the community shopping. The staff loaded the clients into transportation and went back to the program, where they arrived in several minutes. Upon arrival, it was discovered that one of the clients was not with them. The staff immediately returned to the store, and found the client looking at merchandise. Client was fine, did not appear bothered by the situation. The program then contacted the client's family to let them know. Staff were given additional safety training regarding being in the community with clients. Staff involved were then terminated.

The following deficiency is cited as per Title 22 Regulations. Appeal rights given, exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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 02/07/2025 03:34 PM - It Cannot Be Edited


Created By: Todd Tryon On 02/07/2025 at 03:26 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ADULT VOCATIONAL SERVICES INC
FACILITY NUMBER: 312700054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2025
Section Cited
CCR
82078(a)

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(a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. This regulation was not meet as evidenced by: Incident report dated 1/17/25 noted that a client was inadvertently left
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Program Administrator will ensure that all staff who take clients into the community are adequately trained on outings and the process for monitoring clients in the community and procedures for ensuring all clients are accounted for and returned to the program as planned.
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behind at a store during an outing, when all other clients and staff returned to the program. Client was discovered missing from the group, staff went back to store and found client and brought client back to the program unharmed. This caused a potential risk to client's safety.
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The program has removed the staff involved in the incident; and has done training regarding outings and safety in the community.
POC complete 2/7/2025.

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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:Troy Ordonez
LICENSING EVALUATOR NAME:Todd Tryon
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
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