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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700078
Report Date: 08/25/2021
Date Signed: 08/26/2021 09:15:06 AM

Document Has Been Signed on 08/26/2021 09:15 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:VOCATIONAL COACHING AND DEVELOPMENT INSTITUTE INCFACILITY NUMBER:
502700078
ADMINISTRATOR:GREEN, JARED K MA,FACILITY TYPE:
775
ADDRESS:1125 I STREETTELEPHONE:
(209) 342-6707
CITY:MODESTOSTATE: CAZIP CODE:
95354
CAPACITY: 70CENSUS: 25DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sue Crawford and Clayton ForrestTIME COMPLETED:
01:30 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 08/25/2021 by LPA Charlie Yang and was met by a facility designated representative, Clayton Forrest, who was briefly interviewed. It was learned that this program maintained a 6 clients to 1 staff ratio at all times.
Current census was 25 residents.
Tour of the facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed for adequate plates, glassware, and dinnerware sufficient to meet the needs of the residents at this time.
Food supply was not reviewed for 2-day perishable and 7-day nonperishable quantities since the attendees to this program brought their own lunches and snacks on a daily basis.
Medication cabinet, located in the office of manager, was reviewed. Policies and procedures for medication dispensing, documentation, and control were discussed with the facility designated representative. First aid kit was observed to be present and contained all required components at this time.
A tour of the several rooms and spaces intended for client use were toured. A tour of the resident restroom was conducted.
Hot water temperature was taken to make sure that it was within the allowed range of 105-120 degrees.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 08/20/2021 and in compliance at this time.
A tour of the facility exits was conducted. Mitigation plan and procedures were discussed with the facility designated representative.
There were no deficiencies observed or cited during today's annual visit.

The following forms and documents were requested by this LPA to be completed and submitted into CCL:
LIC 308, LIC 400, LIC 500, LIC 610

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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