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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364830600
Report Date: 01/16/2020
Date Signed: 01/16/2020 09:30:33 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:VOLUNTEERS OF AMERICAFACILITY NUMBER:
364830600
ADMINISTRATOR:PAULA JONESFACILITY TYPE:
850
ADDRESS:304 N. PEPPER AVENUETELEPHONE:
(909) 562-0901
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:174CENSUS: 118DATE:
01/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:50 AM
MET WITH:Diana DavilaTIME COMPLETED:
09:45 AM
NARRATIVE
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A case management visit is being conducted by Licensing Program Analyst (LPA) Taadhimeka Zeigler, in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 12/24/2019. It indicates that on 12/19/2019, child #1 was left alone inside of a classroom restroom, with the restroom door closed, while all other children and teachers were outside on the playground. Child #1 was unsupervised.

Facility records were reviewed and staff #1 and #2 were interviewed. Staff #3 is no longer employed. Based on the information gathered, the following violations have been identified: The facility failed to provide care and supervision as necessary to meet the children's needs.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.

An exit interview was conducted, appeal rights discussed, a copy of this report, and a notice of site visit was provided to facility staff.

A copy of this report must be made available to the public for 3 years.

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Taadhimeka ZeiglerTELEPHONE: (951) 680-6745
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOLUNTEERS OF AMERICA
FACILITY NUMBER: 364830600
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2020
Section Cited

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Responsibility for Providing Care and Supervision - The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time.
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This requirement has not been met as evidenced by: Child #1 was left alone, unsupervised, in a classroom restroom, with the door closed, while all other children and staff were outside on the playground. This poses an immediate risk to children in care.
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In the event that training does not take place by POC due date, facility will submit proof of training upon its completion.

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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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Taadhimeka ZeiglerTELEPHONE: (951) 680-6745
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2020
LIC809 (FAS) - (06/04)
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