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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001405
Report Date: 05/11/2022
Date Signed: 05/31/2022 02:21:34 PM

Document Has Been Signed on 05/31/2022 02:21 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: DATE:
05/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mary VelazquezTIME COMPLETED:
12:00 PM
NARRATIVE
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Unannounced case management visit made out to this day program on 05/11/2022 by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua and were met by the Program Director Mary Velazquez and briefly interviewed.
There weren't any clients present at this time since they were out in the community.

The purpose of this case management visit was to discuss the incident which took place on inspection dates 02/12/2020 and 02/25/2020 involving client, C1, and day program staff at that time.
It was learned that C1 was diagnosed with a condition that required constant monitoring from day program staff when it came to items that C1 would attempt to consume. It was reported to this Department on 02/11/2020 that C1 had passed away due to complications from choking on a food item that was salvaged from a trash bin.

The following deficiencies were cited on the following 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes . This facility was cited under Title 22 Rules and Regulations Section 80078 (a) Responsibility for Providing Care and Supervision.

At the time of this case management visit, the issuance of a Civil Penalty was still being determined. However, the Licensee was informed today that a Civil Penalty may be assessed at a later date based on Health & Safety Code Section 1569.49.

Appeal rights were printed and a copy was given to the Program Director at this time.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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 05/31/2022 02:21 PM - It Cannot Be Edited


Created By: Charlie Yang On 05/11/2022 at 11:43 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CENTRAL VALLEY TRAINING CENTER, INC.
FACILITY NUMBER: 507001405

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
80078(a)

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Responsiblity for Providing Care and Supervision
The licensee shall provide care and supervision as necessary to meet the client's needs.
This day program was deficient as evidenced by not properly supervising a client who was diagnosed with Pica. This client was able to
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The facility representative stated that a corrective action plan will be completed and implemented at this day program to address behaviors and staff training for these behaviors from day program clients. A statement of correction, along with corrective action plans, will be completed and submitted into CCL for review by this LPA by the due date.
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retrieve a food item from the trash bin and attempted to hastily consume it. As a result the client choked on the food item and later on passed away.
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A statement of correction and action plan has already been submitted into CCL for review by this LPA.
Plan of correction has been completed.

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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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
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