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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547204112
Report Date: 07/06/2023
Date Signed: 07/06/2023 01:28:26 PM

Document Has Been Signed on 07/06/2023 01:28 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:
07/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Theadosia JohnsonTIME COMPLETED:
12:15 PM
NARRATIVE
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On 7/06/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct a complaint visit and conducted a case management - deficiencies in conjunction with the complaint visit.

LPA observed during arrival, the facility to be undergoing renovations/remodeling. Per Administrator (AD) remodeling is happening in phases and first start date was on 6/26/2023. AD confirmed facility did not report to CCLD because most clients were sent to community inclusions programs, therefore it was determined by facility Management reporting was not necessary. LPA advised AD any changes in the plan of operation which affect the services to clients need to be reported to CCLD in a timely manner.

Deficiency is 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 by Administrator and printed copy provided with appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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Document Has Been Signed on 07/06/2023 01:28 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 07/06/2023 at 12:15 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: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2023
Section Cited
CCR
82061(d)(4)

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82061 Reporting Requirements (d) The items below shall be reported to the licensing agency within 10 working days following the occurrence. (4) Any changes in the plan of operation which affect the services to clients.

This requirement was not met as evidenced by:
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Administrator (AD) agrees to immediately work on SIR to report remodeling of facility to CCLD. AD will include details of how long remodeling is expected, and how client’s needs are being met. AD will submit to CCLD by due date.
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Facility made changes to operations to have clients attend more community inclusions programs therefore changes were made to the plan of operations that affected the services to clients without reporting to CCLD.
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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: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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