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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390308140
Report Date: 11/21/2022
Date Signed: 11/21/2022 12:46:23 PM

Document Has Been Signed on 11/21/2022 12:46 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CENTRAL VALLEY TRAINING CENTER, INC.FACILITY NUMBER:
390308140
ADMINISTRATOR:RAYMOND NYLENFACILITY TYPE:
775
ADDRESS:7603 MURRAY DRIVETELEPHONE:
(209) 951-1504
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 90CENSUS: 48DATE:
11/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Michael CarrollTIME COMPLETED:
12:50 PM
NARRATIVE
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On 11-21-22 at 10:41am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident reported on 11-8-22. LPA met with Program Director Michael Carroll and explained the purpose of the visit. LPA reviewed incident report dated 11-8-22 and reviewed individualized program plan (IPP) for resident1 (R1). LPA also reviewed file documentation for staff1 (S1). Additionally, LPA interviewed program director. Based on interviews and record reviews, it was determined that on 10-28-22, R1 purchased alcohol with another substance from a smoke shop and gave said items to R2 resulting in R2's hospitalization on 10-29-22. It was further determined that R1 was not supervised by S1 while in the smoke shop while R1 was purchasing items; additionally, S1 was unaware of the items purchased by R1.. Upon further review and interview, it was determined that R1 is to be kept under close supervision and not be in possession of any drugs or alcohol as part of R1's probation restrictions. Furthermore, it was determined that S1 was aware of the need for necessary supervision of R1. Program administrator was made aware of this incident on 11-1-22 by licensed facility in which R1 resides. A report was generated accordingly and sent to licensing department and other required parties.

Based on interview and record review, it is determined that R1 was without proper staff supervision leading to the health and safety risk of R1 and R2. As a result, citation is issued today under Title 22, Division 6. Additionally an immediate civil penalty of $500 is issued due to absence of supervision. An exit interview was conducted with Michael Carroll and a copy of this report was left with Michael. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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 11/21/2022 12:46 PM - It Cannot Be Edited


Created By: Michael Bilger On 11/21/2022 at 11:53 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CENTRAL VALLEY TRAINING CENTER, INC.
FACILITY NUMBER: 390308140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2022
Section Cited
CCR
82078(a)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services...This requirement was not met as evidenced by:
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Licensee will conduct staff training on proper procedures on care and supervision. Licensee will submit a scheduled training date by POC due date, and submit proof of completed training no later than 2 weeks from the date of this citation issuance.
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Based on interview and record review, R1 was without proper supervision on 10-28-22 resulting in R1's possession of alcohol with another substance, and R1 giving substance to R2. This posed an immediate health and safety risk to residents in care. An immediate civil penalty is issued in addition to citation issued.
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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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022


LIC809 (FAS) - (06/04)
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