191501798-7-22-2019-33-CC-BBEL-BEC3XU-20190722183857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191501798
Report Date: 07/22/2019
Date Signed: 07/22/2019 06:39:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	ABILITY FIRST		FACILITY NUMBER:	191501798
ADMINISTRATOR:	JULIE MARTIN		FACILITY TYPE:	840
ADDRESS:	480 SOUTH INDIAN HILL BLVD.		TELEPHONE:	(909) 621-4727
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	58	CENSUS: 23	DATE:	07/22/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Director Julie Martin		TIME COMPLETED:	06:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An unannounced Case Management-Incident inspection was conducted on this date by Licensing Program Analyst (LPA) Emiko Bell to follow up on an Unusual Incident which occurred on 07/17/19 and was reported via fax to Community Care Licensing (CCL) at 6:56 P.M. on 07/18/19. LPA arrived at the Center at 9:05 A.M. and was greeted by Director Julie Martin at 9:10 A.M. while reviewing the Parent Board. The purpose of the inspection was then announced to Director Martin. Director Martin then guided LPA to the white board where the names of the children and staff are listed and then to the playground to take census. There were 23 participants with 8 staff. Staff-child ratio was met. The Unusual Incident which was reported that occurred on 07/17/19 was that Child #1 eloped from a group while on a field trip and was found by park rangers. During today's inspection, interviews were conducted in-person on-site with two staff. Documentation in the form of an "Off Site Trip Planning Form" dated 07/15/19; an "Off Site Trip" form dated 07/17/19; the business card of a park ranger; an e-mail dated 07/18/19 from Staff #2; the Unusual Incident/Injury Report faxed to CCL; the Special Incident Report faxed to San Gabriel Pomona Regional Center dated 07/18/19; the written statements of Page 1/2

SUPERVISOR'S NAME: Adriana Hernandez	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: ABILITY FIRST	FACILITY NUMBER: 191501798
	VISIT DATE: 07/22/2019

NARRATIVE

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staff #3, #4 and #5; a list of questions posed during the investigation by the Chief of Programs, a floor plan of the Observatory, a letter given to participants' families dated 07/22/19, and copies of seven documents from the file of Child #1 which include the "Program Application Form," "Individual Intake Form," "30 Day Observation" form, two "Individual Service Plans," and a "Progress Report."

The investigation will continue in order to obtain further documentation and to conduct more interviews, including visiting the site where the incident occurred. Upon the outcome of the investigation, LPA will determine whether citations shall be issued and civil penalties shall be assessed. The CCL Legal Department may be contacted as well.

An exit interview has been conducted with Director Julie Martin. The Notice of Site Visit was posted on Parent Board in LPA's presence. The Notice of Site Visit shall be posted for thirty (30) consecutive days. Failure to maintain posting as required will result in the issuance of a citation and the assessment of a $100 civil penalty.

SUPERVISOR'S NAME: Adriana Hernandez	TELEPHONE: (323) 981-3362
LICENSING EVALUATOR NAME: Betty Bell	TELEPHONE: (323) 981-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2019

LIC809 (FAS) - (06/04)

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