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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004947
Report Date: 09/19/2024
Date Signed: 09/24/2024 09:14:00 AM

Document Has Been Signed on 09/24/2024 09:14 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:VALLEY CAPS PLUSFACILITY NUMBER:
397004947
ADMINISTRATOR/
DIRECTOR:		TAMRA HERNANDEZFACILITY TYPE:
775
ADDRESS:1180 N. UNION ROADTELEPHONE:
(209) 239-5050
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 75CENSUS: 49DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Tamra HernandezTIME VISIT/
INSPECTION COMPLETED:
01:30 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
Unannounced annual visit made out to this facility on 09/19/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Assistant Program Manager, Rachelle Munoz, who was requested by this LPA to go ahead and inform the facility designated Administrator, Tamra Hernandez, that CCL was present at this time.
The facility designated Administrator arrived shortly thereafter to this day program. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 49 residents.
This facility was vendorized to accept and retain residents through Valley Mountain Regional Center at this time. This facility was expected to maintain an 8:1 ratio of participants to staff at all times. It was learned that there were (7) staff members present at this time.
A tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. It was learned that this space was mainly used to store any food items that required refrigeration and no cooking was being conducted at this time.
A tour of the dining area, classrooms, and all other areas intended for client use was conducted.
Medication cabinet, located in a staff office, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of client medications was discussed with the facility designated Administrator. This medication cabinet was observed to be locked and made inaccessible to the clients at this time.
It was learned that there weren't any clients who brought medications to this day program at this time.
First aid kits were observed to be present and contained all of the required components at this time.
A tour of the day program main room and additional classroom settings was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the clients at this time.
Hot water temperatures was taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Supply room housing cleaning agents and supplies was observed to locked and made inaccessible to the
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VALLEY CAPS PLUS
FACILITY NUMBER: 397004947
VISIT DATE: 09/19/2024
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
26
27
28
29
30
31
32
clients at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 12/08/2023 by the local fire extinguisher company, Jorgensen & Co., and in compliance at this time.
Exterior grounds of this facility were toured.
A review of the facility perimeter fence, side gate, and exits was conducted.
An additional storage shed was observed to be present and in use at this time. A brief tour of this shed was conducted. It was observed to be locked and made inaccessible to the clients at this time.

A review of (5) facility resident records was conducted and noted on the following LIC 858.
A review of (5) facility staff records was conducted and noted on the following LIC 859.

The following forms and documents were requested 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: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2