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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005660
Report Date: 10/03/2022
Date Signed: 10/05/2022 08:58:06 AM

Document Has Been Signed on 10/05/2022 08:58 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NEW VISION SERVICES INC. SOUTHFACILITY NUMBER:
397005660
ADMINISTRATOR:TANYA SLOANFACILITY TYPE:
735
ADDRESS:702 SCOOTER WAYTELEPHONE:
(209) 851-8591
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: DATE:
10/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tanya SloanTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kesha Lewis and Albert Johnson conducted an unannounced case management visit to the facility on 10/03/2022 to follow up on an incident that occurred on 9/18/22.

LPA reviewed special incident report stating R1 had attacked staff and another resident. R1 had . R1 had been bitten on the arm by R2 , staff had water thrown at them and their hair pulled and R2 hit S1 several times.

During today's visit, LPA reviewed R2 file. The facility is providing respite care for R2. They have patch funding. R2 came from a negotiated rate home. The facility is trying to get R2 moved because he is not a good fit with other residents in care.

LPA requested updated copies via email to LPA by October 17th, 2022 Emergency Disaster Plan/Infection control Monkey pox. Kesha.Lewis@dss.ca.gov

Exit interview was conducted with Staff.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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