Facility Evaluation Report, 11/29/2023 — Central Valley Training Center, INC., Stockton CA

On 11-29-23 at 12:32pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a client fall. LPA met with Program Coordinator Karla Ledesma and explained the purpose of the visit. LPA reviewed individualized program plan (IPP), and physician report for resident1 (R1). LPA also reviewed incident report dated 11-9-23 and interviewed staff1(S1) and R1. Based on record reviews and interviews, it was determined that on 10-24-23, R1 fell in the parking lot near a transport van. After the fall, staff questioned R1 if he was "ok", to which R1 replied he was "fine...and not watching where he was walking." Staff on duty asked R1 if he needed medical attention to which R1 replied, "no." On 10-30-23, R1 arrived to the day program with a bruise on his left calf. Staff on duty asked R1 if he was "okay" to which R1 replied "yes." According to incident report, R1 was offered medical treatment by staff but refused. On 11-8-23, R1 arrived at the day program with a clearance note from R1's physician stating he was ok to return to program, and further stated R1 was treated and released from the emergency room on 11-7-23 due to leg pain. Record reviews and interviews revealed emergency room trip was due to the fall which occurred on 10-24-23 and due to leg pain and swelling. Interviews further revealed R1 also hit his head during the 10-24-23 fall.

Additionally, 9-1-1 was not notified by day program on 10-24-23 or 10-30-23, nor was a transportation arranged as a provision to initiate medical services. LPA reviewed photos submitted by facility which illustrate R1's bruising on left calf, left ankle, and left leg. Interviews and record reviews further revealed that R1 did not sustain any broken bones or blood clots and is current attending program at this time.

Based on today's case management, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Karla Ledesma and a copy of this report was provided to Karla. Appeal rights provided.