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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701633
Report Date: 08/27/2025
Date Signed: 08/27/2025 01:37:24 PM

Document Has Been Signed on 08/27/2025 01:37 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VALLEY CAPSFACILITY NUMBER:
502701633
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, TAMRAFACILITY TYPE:
775
ADDRESS:108 CAMPUS WAYTELEPHONE:
(209) 576-1807
CITY:MODESTOSTATE: CAZIP CODE:
95380
CAPACITY: 150CENSUS: 71DATE:
08/27/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Tamra Hernandez, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 08/27/2025, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to complete a post-licensing inspection. Upon entry, LPA Campbell met with Program Director Tamra Hernandez and Nathan Ayala, Assistant Program Director and explained the purpose of the visit.

LPA Campbell toured the building for the day program and observed participants socializing, eating the lunch they had brought and watching TV. The facility is licensed to serve 126 ambulatory adults who are ages 18 and over who are developmentally disabled. Twenty four of the participants may be non-ambulatory.

During a tour of the physical plant, a soda machine in the buildings common area was observed to be for the use of participants and staff. LPA Campbell conducted an inspection that included, bathrooms, class rooms, common areas, offices and outdoor space. The thermostat for the physical plant was set at 70 degrees Fahrenheit. Hot water in the bathroom was observed to be 112 degrees Fahrenheit. Hot water in the kitchen was measured at 109 degrees Fahrenheit both of which is between the required 105 degree F (41 degree C) and 120 degree F (49 degree C). Fire extinguishers were last inspected on 12/05/2024. Cleaning products in the kitchen were locked up above the sink. Sharps were made inaccessible under the sink.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
FACILITY NUMBER: 502701633
VISIT DATE: 08/27/2025
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Outdoor space was observed to be unobstructed with grass and seating. Staff stated that umbrellas were available for outdoor tables when needed. Storage for additional cleaning products for the physical plant was observed to be next to the back door and locked. LPA Campbell observed a See Something Say Something poster viewable by participants, staff and visitors. Several first aid kits were observed in the Med Room containing, scissors, tweezers, thermometers and the First Aid Manual were available along with an AED machine. LPA Campbell also observed medicine for participants.

A fire drill log book was reviewed. Fire drills were conducted every three months.

Of the 150 participants enrolled, LPA Campbell reviewed 5 files. Of the 30 staff employed, LPA Campbell reviewed 3 files. All files were found to be complete.
No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Tamra Hernandez.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
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