<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602128
Report Date: 11/10/2021
Date Signed: 11/10/2021 10:09:11 AM

Document Has Been Signed on 11/10/2021 10:09 AM - 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:VOCATIONAL INNOVATIONSFACILITY NUMBER:
198602128
ADMINISTRATOR:PATEL, MANDAKINIFACILITY TYPE:
775
ADDRESS:1532 E SAN BERNARDINO B1-B5TELEPHONE:
(909) 971-3280
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 60CENSUS: 27DATE:
11/10/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Staff member, Zaira SilvaTIME COMPLETED:
10:20 AM
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
Licensing Program Analyst (LPA) Vasallo conducted a Collateral Visit to the day program. The purpose of the visit was to interview Client #1 (C1) regarding an incident at C1's facility. C1 was interviewed in a conference room with a staff member present. Once interview ended, the visit was completed.

Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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 1