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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001405
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:25:05 PM

Document Has Been Signed on 08/13/2024 04:25 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/
DIRECTOR:		MARY VELAZQUEZFACILITY TYPE:
775
ADDRESS:1405 KANSAS AVENUE, SUITE CTELEPHONE:
(209) 522-0332
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 126CENSUS: 144DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Mary Velasquez, Interim Regional DirectiorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to conduct a case management and met with Interim Regional Director Mary Velasquez regarding an incident report sent on 08/13/24 when C1, who is non-verbal, was allegedly hit by staff. During the visit, LPA Campbell interviewed D1 about what they had heard on the day of the incident. LPA Campbell also requested that a LIC855 form be filled out by D1, S1, S2 and S3, regarding what they had heard or witnessed.

Immediately after the incident, staff assessed C1 for any possible injuries and C1’s responsible party was notified. No injuries were observed by staff. C1 was then allowed to go about their day in the program. Per D1, the facility conducted an investigation and could not substantiate that S4 hit C1 as no one directly saw C1 being hit. However, S4 was found to have exhibited unprofessional behavior and was given a Notice of Termination. Continued trainings for staff were then scheduled for their next All-Staff Meeting on the topic of Rules of Conduct.

At this time, no deficiencies have been cited.

An exit interview was conducted and a copy of this report were provided.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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