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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390312660
Report Date: 10/26/2021
Date Signed: 10/26/2021 04:50:08 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/26/2021 04:50 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:VALLEY CAPS ABLEFACILITY NUMBER:
390312660
ADMINISTRATOR:TAMRA HERNANDEZFACILITY TYPE:
775
ADDRESS:178 SOUTH AUSTINTELEPHONE:
(209) 239-5050
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 135CENSUS: 4DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:T. HernandezTIME COMPLETED:
12:30 PM
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LPA Albert Johnson made an unannounced required annual inspection to this facility today. LPA met with T. Hernandez.

This Day Program operates as a 515 Day Program vendorized by VMRC (Valley Mountain Regional Center). During today's visit, there are 4 clients present. LPA toured the facility inside and out with Staff. LPA inspected 2 rooms, facility bathrooms and client and staff records. Facility is performing disaster drills as required. The facility administers medications for several client. Fire extinguishers and smoke detectors are operational. Fire Drill was conducted on 9/2021. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 4 resident and 4 staff files, including criminal record clearances. All staff are fingerprint cleared.

Water temperature measured at 126 degrees in the women's bathroom, which is not within the required range of 105 to 120 degrees. Exits were observed to be accessible to clients and free from obstructions. LPA observed a Satisfactory Highway patrol fleet inspection dated 1/2021.

There were deficiencies found and cited from the California Code of Regulations - Title 22 and cited on the LIC 809-D. If the deficiencies are not corrected by the noted due date civil penalties may be assessed. Exit interview conducted and appeal right given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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 10/26/2021 04:50 PM - It Cannot Be Edited


Created By: Albert Johnson On 10/26/2021 at 12:12 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: VALLEY CAPS ABLE
FACILITY NUMBER: 390312660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2021
Section Cited
CCR
82088(e)(1)

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(e) Faucets used by clients for personal care shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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The Director shall adjust the hot water temperature to no less than 105 degrees F degrees and not more than 120 degrees F. LPA requested the facility take a water temperature and log measurement twice a day for (3) days and submitted to CCL by 10/29/2021.
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Requirement not met: LPA measured temperature of 126 degrees Fahrenheit posing an immediate health and safety risk.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
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