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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801934
Report Date: 07/31/2025
Date Signed: 07/31/2025 03:32:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250724131445
FACILITY NAME:COLE VOCATIONAL SERVICES COVINA 2FACILITY NUMBER:
197801934
ADMINISTRATOR:MATT PORPORAFACILITY TYPE:
775
ADDRESS:515 S 2ND AVETELEPHONE:
(626) 915-6678
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY:45CENSUS: 34DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Angie Fraijo - Program DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff was sleeping while providing care and supervision.
Staff are operating out of ratio.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an initial 10 days complaint visit and investigate the above allegations. LPA met with Miriam Maldonado (Area Director) and Angie Fraijo (Program Director) and explained the reason of the visit.

The investigation consisted of the following:

LPA obtained copies of Staff/Client Rosters, Copy of San Gabriel/Pomona Regional Center Ratio Requirements, Documents within Client #1-3 files, Termination information for Staff #1, and LPA interviewed 4 Staff (S2-5) and 4 Clients (C1, C4-C6).

(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20250724131445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COLE VOCATIONAL SERVICES COVINA 2
FACILITY NUMBER: 197801934
VISIT DATE: 07/31/2025
NARRATIVE
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The investigation revealed the following:
Allegation: Staff was sleeping while providing care and supervision
It is alleged that on 7/11/25, S1 was observed sleeping while providing care and supervision to clients C1-C3 during their lunch break. LPA interviewed 4 staff and 3 out of 4 staff confirmed the above allegation, interviews with S2 and S3 revealed that S1 was observed sleeping and while providing supervision to clients C1-C3 during their lunch time and has since been terminated from employment with organization. LPA interviewed 4 clients and 1 out of 4 clients confirmed the above allegation, interview with C1 revealed they were present and observed S1 sleeping while providing care and supervision to clients.

Allegation: Staff are operating out of ratio
It is alleged that facility was operating out of ratio on 11 different occasions in June 2025 and 4 different occasions in July 2025. LPA reviewed Title 17 requirements, and it was observed that facility should be operating with a 1:3 ratio. LPA interviewed 4 staff and 4 out of 4 staff interviewed confirmed the above allegation and stated that although their ratio should be 1:3 (one staff to 3 participants) they often operate with a 1:4 ratio as there are staff call offs, interviews with S2 and S3 revealed that facility is actively trying to hire additional staff but have not yet been able to bring enough staff on board to operate within Regional Centers required 1:3 ratio. LPA interviewed 4 clients and 3 out of 4 clients confirmed the above allegation and stated there is usually 1 staff for every 3 clients, however, often times there will be 4 clients to 1 staff.

Based on LPAs observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 6 and Chapter 3 are being cited on the attached LIC 9099-D. Exit interview held, and a copy of this report and appeal rights were emailed to Program Director.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250724131445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2025
Section Cited
CCR
82065(a)
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82065 Personnel Requirements (a) Program personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This standard is not met at evidence by:
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Program Director to provide a written statement/plan as to how they will ensure that staff will remain awake during their shift and provide this statement/plan to LPA via email by POC due date. Additionally Program Director indicated that a training will be conducted on 8/4/25 that will cover policies which include staff being awake during working hours, copy of training materials that cover this policy and copy of participant list with signatures shall be emailed to LPA by POC due date. tena.herrera@dss.ca.gov
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Interviews revealed that S1 was observed sleeping while on shift, and has since been terminated from facility due to this incident.
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Type B
08/14/2025
Section Cited
CCR
82065.5(a)(1)
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82065.5 Staff-Client Ratio (a) Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met: (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center.
This standard is not met at evidence by:
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Program Director to provide LPA with a written plan on how they will ensure that facility will operate within the required ratio and email plan to LPA by POC due date. tena.herrera@dss.ca.gov
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Interviews and record review revealed that facility should be operating with a 1:3 ratio and are often times operating with a 1:4 ratio.
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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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3