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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001405
Report Date: 05/10/2022
Date Signed: 05/31/2022 02:20:59 PM

Document Has Been Signed on 05/31/2022 02:20 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:
05/10/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mary VelazquezTIME COMPLETED:
11:00 AM
NARRATIVE
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Announced office visit was conducted on 05/10/2022 by Licensing Program Manager (LPM) Stephenie Doub, Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua and other day program representatives. In attendance were the following day program representatives:

April Howell- Program Coordinator
Jennifer Jones- Regional Director
Mary Velazquez- Program Director
Sonya Fox-Watson- Chief Operations Director

The purpose of this office visit, conducted via Microsoft Teams, was to discuss the incident which took place on inspection date 07/30/2018 involving client, C1, and day program staff at that time. LPM Stephenie Doub proposed questions in regards to the day program and any changes that have been put into place in regards to this incident. Day program representatives stated that all changes and updates will be gathered and submitted into CCL for review by LPA Charlie Yang on COB 05/11/2022.

The following deficiencies were cited on 10/26/2018 on the following 809-D, per Title 22 Rules and Regulations, Division 6. This facility was cited under Title 22 Rules and Regulations Section 80078 (a) Responsibility for Providing Care and Supervision. At the time of the investigation on 10/26/2018, 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.

A copy of this report will be scanned and sent, via email, to the Program Director, Mary Velazquez, for her to sign and submit back to LPA Charlie Yang.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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