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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004947
Report Date: 10/21/2021
Date Signed: 10/26/2021 04:15:09 PM

Document Has Been Signed on 10/26/2021 04:15 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 PLUSFACILITY NUMBER:
397004947
ADMINISTRATOR:TAMRA HERNANDEZFACILITY TYPE:
775
ADDRESS:1180 N. UNION ROADTELEPHONE:
(209) 239-5050
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 75CENSUS: 13DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Johnson and Tamra HernandezTIME COMPLETED:
12:00 PM
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Unannounced annual visit made out to this day program on 10/21/2021 by LPA Charlie Yang and was met by the facility representative, Jessica Johnson, who was briefly interviewed. This LPA also requested that the facility designated Administrator, Tamra Hernandez, be notified that CCL was present at this time. The facility designated Administrator arrived shortly thereafter to this day program.
Current census was 13 clients.
This day program maintains an 8:1 ratio for staff to clients.
Tour of this day program was conducted.
All rooms designated as classrooms, activity areas, and common areas for client use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the clients at this time.
Office rooms and other areas intended for client use were toured. It was learned that due to Covid restrictions and guidelines, certain areas were no longer made available for client use in order to maintain social distancing and follow CDC guidelines.
A sample of the day program restrooms was toured.
Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time.
Fire extinguishers, place throughout this day program, were observed to have been annually inspected on 12/04/2020 by the local fire extinguisher company and in compliance at this time.
Kitchen area was toured.
It was observed that there wasn't an oven/stove present since there wasn't any type of cooking or baking done on site at this time. The use of microwaves and a toaster oven were the only methods used to heat and warm up the food of the clients if necessary.
Storage area for chemicals and cleaning supplies was observed to be locked and made inaccessible to the clients at this time.
Exterior grounds of this day program was toured.
Perimeter fence and side gates were observed to be functional and in good repair at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PLUS
FACILITY NUMBER: 397004947
VISIT DATE: 10/21/2021
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Entrances and exits used were observed to be supplied with hand sanitizer and masks at this time.
The following forms and documents were requested by this LPA to be updated and submitted into CCL:

LIC 308
LIC 400
LIC 500
LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC809 (FAS) - (06/04)
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