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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001405
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:51:31 PM

Document Has Been Signed on 11/30/2023 02:51 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: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:
11/30/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Melissa HernandezTIME COMPLETED:
03:00 PM
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On 11/30/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a collateral visit in relation to facility #507001554, complaint # 27-AS-20230920115738. LPA Jensen met Melissa Hernandez and explained the purpose of today's visit.

LPA Jensen requested a copy of the file for Client 1 (C1). LPA Jensen reviewed the Day Program Intake form and the Individual Program Plan written by the Valley Mountain Regional Center from August of 2023. LPA Jensen also reviewed T-logs related to C1 for the months of August, September and October 2023.

LPA Jensen interviewed staff 1 (S1).

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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