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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201522
Report Date: 09/05/2024
Date Signed: 09/05/2024 04:10:40 PM

Document Has Been Signed on 09/05/2024 04:10 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SOCIAL VOCATIONAL SERVICES, INC.FACILITY NUMBER:
435201522
ADMINISTRATOR/
DIRECTOR:		PERKINS, CYNTHIAFACILITY TYPE:
775
ADDRESS:471 GIANNI STREETTELEPHONE:
(408) 727-3370
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 60CENSUS: 60DATE:
09/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Program Director, Ruby DuranTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management to follow up regarding an incident which occurred where client (C1) went missing while attending the day program. LPA Rai met with Program Director, Ruby Duran and stated the purpose of today's visit.

On 9/3/2024, C1 and three other clients went to the local library as part of the community activity scheduled for the day. Staff (S1) was supervising the 4 clients at the library. While at the library, C1 left the library. At this time, C1 has not returned back to the day program or C1's residential facility.

During today's visit, LPA Rai interviewed Program Director and Staff (S1). Clients were not present at the facility.

Program Director stated she did not report the incident since it had occurred out in the community and the incident did not occur in the facility. LPA Rai stated if the client is attending day program and is out in the community due to a scheduled activity, then it is the responsibility of the day program to report the incident since the client was under the care and supervision of the day program staff. Program Director agreed and understood. During today's visit, LPA Rai issued a deficiency due to the facility staff did not notify licensing agency regarding C1 leaving the library which was a scheduled activity while attending day program.

LPA Rai determined that this case management require further investigation to obtain additional information.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Plan of Correction (POC) for Type B deficiency issued during today's visit will be due on Thursday, September 12th, 2024. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Program Director, Ruby Duran and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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 09/05/2024 04:10 PM - It Cannot Be Edited


Created By: Simranjit Rai On 09/05/2024 at 03:29 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SOCIAL VOCATIONAL SERVICES, INC.
FACILITY NUMBER: 435201522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
CCR
82061(a)

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82061 (a) Upon the occurrence, during the hours the day program is providing services to the client, of any of the events specified in Section 82061(a)(1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours.
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Program Director stated to submit a written plan of action understanding regulation and ensure reporting requirements are followed after an incident occurs while clients are attending day program by POC due date. Program Director agreed and understood.
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This requirement is not met as evidenced by: Based on interview and record review, the facility staff did not notify licensing agency regarding C1 leaving the library during an activity while attending day program which poses/posed a potential health, safety or personal rights risk to persons in care.
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During today's visit, Program Director provided a copy of the Special Incident Report sent to San Andreas Regional Center (SARC) and submitted to LPA Rai.

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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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
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