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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507001405
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:11:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20240802154632
FACILITY NAME:CENTRAL VALLEY TRAINING CENTER, INC.FACILITY NUMBER:
507001405
ADMINISTRATOR:MARY VELAZQUEZFACILITY TYPE:
775
ADDRESS:1405 KANSAS AVENUE, SUITE CTELEPHONE:
(209) 522-0332
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY:126CENSUS: 115DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Courtney Kegley, Interim Program DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not adequately supervise clients in care.
INVESTIGATION FINDINGS:
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On 08/06/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the Central Valley Training Center Inc.Day Program to open a complaint. LPA Campbell met with Administratory Mary Velazquez and Interim Program Director Courtney Kegley and explained the purpose of the visit. During the course of the investigation, the Department requested incident reports, the roster for clients and staff and interviewed Client 1(C1) and Staff 1(S1). S1 provided statements to the Department confirming that they had lost sight of C1 who is visually impaired while assisting C2 who was throwing up.

Based on the documents reviewed and the interviews conducted, it was determined that staff did not adequately supervise clients in care. The allegation is therefore determined to be substantiated.
The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1548 H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 27-AS-20240802154632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CENTRAL VALLEY TRAINING CENTER, INC.
FACILITY NUMBER: 507001405
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2024
Section Cited
HSC
82078(a)
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82078 (a) (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. This requirement was not met as evidenced by:
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Licensee conducted an in service training for staff. A sign in sheet and the training materials used were provided to the Deparment for verification on 08/06/24.
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Based on interviews and record review, staff lost sight of a client and failed to provide care and supervision necessary to meet the clients needs. This posed an immediate health and safety risk to resident in care.
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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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
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