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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390308140
Report Date: 09/06/2023
Date Signed: 09/06/2023 03:57:07 PM

Document Has Been Signed on 09/06/2023 03:57 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: 82DATE:
09/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Michael CarrollTIME COMPLETED:
04:07 PM
NARRATIVE
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On 9-6-23 at 12:45pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management regarding an incident reported on 9-1-23. LPAs met with Program Administrator Michael Carroll and explained the purpose of the visit. LPAs conducted interviews with Staff1 (S1), S2, and S3 and conducted a facility observation. LPAs also attempted interview with resident1 (R1). LPAs also reviewed additional facility file documentation. Based on record reviews and interviews it was determined that on 8-30-23, staff on duty heard a slap and witnessed R1's hand in motion from the corner of staff's eye, and thought R1's hand was slapped by staff4 (S4) sitting next to R1. It was further determined that on 8-31-23, a staff member witnessed S4 slap R1 on the right hand with force and in a punitive nature while R1 was attempting to reach for an object. Record reviews and interviews conducted further revealed R1 was holding R1's hand and appeared to be in pain.

Incident occurring on 8-30-23 and 8-31-23 was made known to program administrator on 8-31-23. The incident occurring on 8-31-23 was reported to licensing department, ombudsman, and local law enforcement within regulatory time frames. R1's hand was observed by facility staff to not appear bruised, however, R1 was not sent to urgent care or other emergency services to confirm any non-injury. Based on interview and record review, it was revealed that the event occurring on 8-30-23 was not reported to licensing department, ombudsman, or local law enforcement. Based on review of incident report and interviews, S4, who was witnessed to have slapped R1's hand stated while laughing: "She asked for it." Additional record reviews revealed elder abuse training was completed for S1, S2, S3, and S4.

Based on today's case management, citations are issued under Title 22, Division 6. An exit interview was conducted with Michael Carroll and a copy of this report was provided to Michael. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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 09/06/2023 03:57 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/06/2023 at 02:51 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
, 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: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2023
Section Cited
CCR
80072(a)(3)

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Personal Rights. (a) ...each client shall have personal rights which include, but are not limited to, the following: (3) To be free from...unusual punishment, infliction of pain, humiliation, intimidation, ridicule...This requirement was not met as evidenced by:
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Licensee to ensure completed staff training on appropriate staff to client interactions.
Licensee to ensure completed staff training on client personal rights. Training dates to be submitted to LPA by POC due date and proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance.
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Based on interview and record review, facility staff slapped R1's hand in a punitive manner and with force while R1 was attempting to reach for an object, This posed an immediate risk to health, safety, and resident rights risk to residents in care.
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Type A
09/07/2023
Section Cited
CCR82075(a)

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Health Related Services. (a)The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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Licensee to ensure completed staff training on timely medical attention to clients needs. Training date to be submitted to LPA by POC due date and proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance.
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Based on interview and record review, R1 sustained a slap and observance of pain on 8-31-23 and medical attention was not initiated to rule out any injury. This posed an immediate health and safety risk to residents in care.
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Licensee to ensure initiation of medical service for R1 to include physician's examination and additional services such as X-rays as deemed necessary by physician. Proof of services initiated to be sent to LPA by POC due date.
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: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/06/2023 03:57 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/06/2023 at 03:16 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
, 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: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2023
Section Cited
CCR
80061(d)

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Reporting Requirements. (d) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by:
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Licensee to ensure completed staff training on abuse reporting requirements. Proof of completed training to be sent to LPA by POC due date.
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Based on interview and record review, an incident of suspected adult abuse occurring on 8-30-23 was not reported to licesning department, ombudsman, and local law enforcement per regulatory requirements. This posed a potential health and safety risk to residents in care.
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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: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


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