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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547204112
Report Date: 09/13/2023
Date Signed: 09/13/2023 01:11:06 PM

Document Has Been Signed on 09/13/2023 01:11 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SOCIAL VOCATIONAL SERVICES, VISALIA #2FACILITY NUMBER:
547204112
ADMINISTRATOR:THEADOSIA JOHNSONFACILITY TYPE:
775
ADDRESS:3140 WEST CALDWELL AVENUETELEPHONE:
(559) 735-0938
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 75CENSUS: 64DATE:
09/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Theadosia Johnson, AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
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On 9/13/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct a case management visit regarding a SOC 341 received on 8/28/2023 by CCLD and follow up on unpaid Facility annual fees.

LPA conducted an Interview with Administrator and was informed based on facilities’ investigation the ex-employee (S1) did treat a client (C1) with disrespect as alleged on the SOC 341. LPA discussed with the Administrator the outstanding Facility Annuel and late fees. LPA reviewed the notes from previous visit by (LPA) M. Thao informing AD to pay the fees or a deficiency may be cited.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with Administrator. Report signed on-site and printed copy provided with appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/13/2023 01:11 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/13/2023 at 12:20 PM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SOCIAL VOCATIONAL SERVICES, VISALIA #2
FACILITY NUMBER: 547204112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2023
Section Cited
CCR
82072(a)(1)

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82072 Personal Rights (a) Each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidenced by:
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 Administrator to complete in-service training with all staff in regards to Personal Rights to insure similar incidents do not occur in the future.
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Based on SOC 341 report and interviews conducted a client was treated disrespectfully which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/27/2023
Section Cited
CCR82036(a)(1)(a)

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82036(a)(1)(a)
(a) An applicant or a licensee shall be charged fees as specified in Health and Safety Code Section 1523.1. (1) Health and Safety Code Section 1523.1 provides in part...After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license...
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Licensee agrees to pay the licensing fees to bring the facility annual fees current by the POC due date. LPA provided Administrator with the PIN to pay licensing fees online.
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Based on record review, the licensee did not ensure the above regulation was met as evidenced by the facility licensing fees being past due in the amount of $567 which poses/posed a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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