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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004105
Report Date: 03/18/2024
Date Signed: 03/18/2024 10:21:12 AM

Document Has Been Signed on 03/18/2024 10:21 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:COLE VOCATIONAL SERVICES CSIP LONG BEACHFACILITY NUMBER:
306004105
ADMINISTRATOR:SHERRIE SIMILTONFACILITY TYPE:
775
ADDRESS:3826 ATLANTIC AVETELEPHONE:
(562) 426-4870
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 30CENSUS: 37DATE:
03/18/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Crystal Robertson & Sylvia Hernandez TIME COMPLETED:
10:29 AM
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On 03/18/24, Licensing Program Analyst( LPA) Ernand Dabuet initiated a Collateral visit at this facility. LPA met with Program Supervisors Crystal Robertson and Sylvia Hernandez. LPA explained the purpose of this visit is to gather information regarding a current complaint about REM California LLC - E. 213th facility complaint number 11-AS-20240315083753.

The visit consisted of an interview with client #1 (C1) who is a client at REM California, LLC # 213th facility. Details on the interview is documented on LIC 812 crossed reference with REM California, LLC - 213th #198320232.

During the visit, LPA requested copies of (C1's) Physician's Report LIC 602 (dated: 08/29/23), Individual Profile, Physician's Order Sheet (dated: 11/22/22) Harbor Regional Center Individual Personal Plan (dated: 01/17/24), and Prescribe Medications Side Effects.

An exit interview was conducted with Crystal Robertson, and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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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