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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700298
Report Date: 04/12/2022
Date Signed: 04/12/2022 01:13:46 PM

Document Has Been Signed on 04/12/2022 01:13 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:DIZON VALLEY CARE HOMEFACILITY NUMBER:
392700298
ADMINISTRATOR:DIZON, LISSETFACILITY TYPE:
735
ADDRESS:2830 SAN ROCCO DRTELEPHONE:
(510) 435-7428
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 4DATE:
04/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary BaldwinTIME COMPLETED:
01:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) arrived unannounced to conduct a complaint investigation, as a result a case management was opened to address the lack of criminal background clearance for S2.

Case management visit regarding a background check on S2. Lack of records indicate that the referenced individuals did not have a clearance or request an exemption.

Identified individuals shall not be allowed on the facility premises nor have any contact with clients unless a criminal record clearance is obtained.

Deficiencies cited during todays visit along with civil penalties.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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 04/12/2022 01:13 PM - It Cannot Be Edited


Created By: Albert Johnson On 04/12/2022 at 12:49 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: DIZON VALLEY CARE HOME
FACILITY NUMBER: 392700298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
Section Cited
CCR
80019(e)(2)

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Criminal Record Clearance. All individuals subject to a criminal record review shall, prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance.
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Administrator is to request criminal record clearance for S2 by POC date.
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**S2 does not have a criminal record clearance or a file for this facility. An immediate civil penalty in the amount of $500.00.
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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: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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