<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390308140
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:43:25 PM

Document Has Been Signed on 11/29/2023 02:43 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 78DATE:
11/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Karla LedesmaTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11-29-23 at 12:32pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a client fall. LPA met with Program Coordinator Karla Ledesma and explained the purpose of the visit. LPA reviewed individualized program plan (IPP), and physician report for resident1 (R1). LPA also reviewed incident report dated 11-9-23 and interviewed staff1(S1) and R1. Based on record reviews and interviews, it was determined that on 10-24-23, R1 fell in the parking lot near a transport van. After the fall, staff questioned R1 if he was "ok", to which R1 replied he was "fine...and not watching where he was walking." Staff on duty asked R1 if he needed medical attention to which R1 replied, "no." On 10-30-23, R1 arrived to the day program with a bruise on his left calf. Staff on duty asked R1 if he was "okay" to which R1 replied "yes." According to incident report, R1 was offered medical treatment by staff but refused. On 11-8-23, R1 arrived at the day program with a clearance note from R1's physician stating he was ok to return to program, and further stated R1 was treated and released from the emergency room on 11-7-23 due to leg pain. Record reviews and interviews revealed emergency room trip was due to the fall which occurred on 10-24-23 and due to leg pain and swelling. Interviews further revealed R1 also hit his head during the 10-24-23 fall.

Additionally, 9-1-1 was not notified by day program on 10-24-23 or 10-30-23, nor was a transportation arranged as a provision to initiate medical services. LPA reviewed photos submitted by facility which illustrate R1's bruising on left calf, left ankle, and left leg. Interviews and record reviews further revealed that R1 did not sustain any broken bones or blood clots and is current attending program at this time.

Based on today's case management, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Karla Ledesma and a copy of this report was provided to Karla. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/29/2023 02:43 PM - It Cannot Be Edited


Created By: Michael Bilger On 11/29/2023 at 02:11 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: CENTRAL VALLEY TRAINING CENTER, INC.
FACILITY NUMBER: 390308140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
82075(a)

1
2
3
4
5
6
7
82075 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:
1
2
3
4
5
6
7
Licensee will ensure completed staff training on when to provide needed medical services to client in care including procedures. Proof of completed training to be sent to LPA by POC due date.
8
9
10
11
12
13
14
Based on record reviews and interviews, R1 sustained a fall on 10-24-23 and staff did not initiate a 9-1-1 call or arrange for transportation to emergency department to provide medical services. This posed a potential health and safety risk to resident in care.
8
9
10
11
12
13
14
Licensee will read regulation 82075(a) and provide a signed declaration of understanding to LPA by POC due date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2