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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330908141
Report Date: 02/23/2024
Date Signed: 02/23/2024 10:35:07 AM

Document Has Been Signed on 02/23/2024 10:35 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:V.I.P. TOTSFACILITY NUMBER:
330908141
ADMINISTRATOR:KINGSLEY A. BOULDINFACILITY TYPE:
850
ADDRESS:41915 E. ACACIA AVENUETELEPHONE:
(951) 652-7611
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 63TOTAL ENROLLED CHILDREN: 63CENSUS: 29DATE:
02/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Debbie Haney TIME COMPLETED:
10:45 AM
NARRATIVE
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On February 23, 2024, at 9:28 AM. Licensing Program Analyst (LPA) Anastasia Flores, arrived for the purpose of a case management visit. A case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility dated 02/02/24. It indicates that staff #1 (S1) slapped child #1 (C1) in the face, as a form of discipline. The incident dated 2/02/24, was witnessed by staff #2, #3 (S2, S3).

LPA Flores advised Site Director of courses that would be beneficial for the staff, such as Trauma Informed Care, Self Care, Recognizing Self Triggers.

Records were reviewed, interviews were conducted with two staff at time of inspection. Based on the information gathered, the following violations have been identified: See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12. Chapter 1, Article 6, section: 101223(a)(3) Personal Rights.

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Debbie Haney.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Anastasia Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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Document Has Been Signed on 02/23/2024 10:35 AM - It Cannot Be Edited


Created By: Anastasia Flores On 02/23/2024 at 10:01 AM
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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: V.I.P. TOTS
FACILITY NUMBER: 330908141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
101223(a)(3)

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101223(a)(3) Personal Rights: The licensee shall ensure that each child is accorded the following personal rights; To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.This requirement was not met as evidenced by....
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Staff #1 was immediately released from facility, other agencies were notified, Administrator will provide a plan of correction to LPA Flores, via email regarding, how to prevent this type of behavior from occuring in the future. Staff are having a training on social emotional skills on 2/26/24.
Plan of correction will be provided by 3/08/24.
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Based on records reviewed, interviews conducted with two staff, staff #1 slapped child #1 on 2/02/24, no immediate injuries were observed. This poses a potential health, safety or personal rights risk to persons in care.
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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:Pauline Beschorner
LICENSING EVALUATOR NAME:Anastasia Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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