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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005660
Report Date: 05/10/2023
Date Signed: 06/05/2023 10:01:20 AM

Document Has Been Signed on 06/05/2023 10:01 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: 5DATE:
05/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Shmoune JonesTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced case management visit to the facility on 05/10/2023 to follow up on an incident that occurred on 04/14/23.

LPA reviewed special incident report stating R1 had a bruise on their right eye. R1 told day program staff facility staff that it was make up then when asked again by facility staff again it was said that it was make up then when asked by the doctor at ugrent care it was told that there was a fight at day program between a staff and a student and she got hit that was also told to other facility staff and R1'S aunt.

During today's visit, LPA reviewed R1'S file, and took coppies of R1'S IPP showing R1 is known to make up lies. R1 is no longer at the facility.

No deficiencies were observed or have been issued during today's visit.

Exit interview was conducted with Staff and copy of the report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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