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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390308140
Report Date: 07/10/2024
Date Signed: 07/10/2024 11:58:53 AM

Document Has Been Signed on 07/10/2024 11:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CENTRAL VALLEY TRAINING CENTER, INC.FACILITY NUMBER:
390308140
ADMINISTRATOR/
DIRECTOR:		RAYMOND NYLENFACILITY TYPE:
775
ADDRESS:7603 MURRAY DRIVETELEPHONE:
(209) 951-1504
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 90CENSUS: 86DATE:
07/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:03 AM
MET WITH:Michael CarrollTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 7-10-24 at 10:03am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a resident involved incident on 6-24-24. LPA met with Program Director (PD) Michael Carroll and explained the purpose of the visit. LPA reviewed incident documentation and briefly interviewed PD. Based on interview and record review, on 6-24-24, resident1 (R1) was engaged in a behavior episode which involved R1 placing self on the ground and proceed in a rolling and scooting motion which resulted in day program coordinating with R1's facility residence for early departure from the program that day.

R1 returned to his residence on 6-24-24. Behavior episode resulted in various bruising and torn clothing of R1. Day program continues to monitor R1 during program attendance and update care plan accordingly to address behaviors. No citation issued as a result of today's case management.

An exit interview was conducted with Michael Carrol and a copy of this report was provided to Michael.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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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