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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801934
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:57:50 PM

Document Has Been Signed on 10/03/2024 02:57 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COLE VOCATIONAL SERVICES COVINA 2FACILITY NUMBER:
197801934
ADMINISTRATOR/
DIRECTOR:		MATT PORPORAFACILITY TYPE:
775
ADDRESS:515 S 2ND AVETELEPHONE:
(626) 915-6678
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 45CENSUS: 44DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Miriam MaldonadoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Program Director Miriam Maldonado and explained the reason for the visit. The facility is licensed as an Adult Day Program to serve 45 developmentally disabled adults clients ages 18 and older. All clients in the day program receive services provided by San Gabriel / Pomona Regional Center. At the time of visit there were 37 clients at the facility.
The day program is located in the suite of office building which include Lobby, kitchen, 3 bathrooms, Fitness room, Hobby room, Theater room, Changing room, Tech Lounge, Music room, Zen room, Director office, Assistant office, and storage room. There is an outdoor activity area. There is no pool or large body of water at the premises.
LPA toured the facility, and the following were observed: The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. 4 fire extinguishers observed at the facility and are fully charged. The bathrooms were observed to be clean and operational. The water temperature was tested in all 3 bathrooms. In bathroom #2 water temperature tested 75.8 degrees F.
Food is not prepared at this program and clients are able to bring their own food and staff would assist them to heat up the food during lunch time. The kitchen area has a refrigerator where the clients can store their food. The day program has adequate snacks for clients and there's a water dispenser from the refrigerator in the kitchen for client to use. Sharps are kept locked in Director office. LPA observed disinfectant cleaner/spray under the kitchen sink cabinet unlocked and accessible to clients.
Facility does administer medication to one client and the medication is locked in the Assistant office.
The smoke/carbon monoxide detector was observed to be fully operational. The last fire drill was completed in 9/04/2024.

Continue 809C








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SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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 4
Document Has Been Signed on 10/03/2024 02:57 PM - It Cannot Be Edited


Created By: Nune Margaryan On 10/03/2024 at 12:27 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COLE VOCATIONAL SERVICES COVINA 2
FACILITY NUMBER: 197801934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed disinfectant cleaner/spray under the kitchen sink cabinet unlocked and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Disinfectant cleaner/spraywere locked immediately. No further action needed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/03/2024 02:57 PM - It Cannot Be Edited


Created By: Nune Margaryan On 10/03/2024 at 12:27 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COLE VOCATIONAL SERVICES COVINA 2
FACILITY NUMBER: 197801934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. In bathroom #2 water temperature tested 75.8 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Water temperature were adjusted at the time of visit. Program Director will ensure water temperature is maintain within the required 105-120 degrees F.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COLE VOCATIONAL SERVICES COVINA 2
FACILITY NUMBER: 197801934
VISIT DATE: 10/03/2024
NARRATIVE
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A first aid kit was observed in the facility with the required items and a first aid manual was available.
There are storage cabinets/ lockers for the clients and staff belongings.
LPA reviewed 4 staff files. Staff had criminal background clearance and associated to the facility. Staff also has an updated First Aid and CPR certificates. LPA reviewed 4 Client files. Files are located in the Director office / Assistant office and stored in a locked cabinet. The client files consist of the admission agreement, IPP/Appraisal Needs & Services Plan, and medical assessment with the TB results.

During today’s inspection deficiencies observed. See 809D for details.

An exit interview was conducted, and a copy of the report was provided along with appeal rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4