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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364844012
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:22:36 PM

Document Has Been Signed on 03/05/2024 02:22 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:VOLUNTEERS OF AMERICA EHS CC PPFACILITY NUMBER:
364844012
ADMINISTRATOR:CLAVESILLA, ELVIAFACILITY TYPE:
850
ADDRESS:799 E. RIALTO AVENUETELEPHONE:
(909) 332-6690
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92408
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 12DATE:
03/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:CLAVESILLA, ELVIATIME COMPLETED:
02:30 PM
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
On 03/05/2023 Licensing Program Analyst (LPA) Justin Giese conducted an unannounced case management visit to the facility for the purpose of obtaining additional information/investigating the Facility's submission of an Unusual Incident Report (UIR) received on 02/27/2024.The UIR outlined an incident that occurred on 02/23/2024 pertaining to personal rights of a child in care.

LPA discussed purpose of this visit with the Facility Director, took census, collected/reviewed documents and conducted interviews. Due to insufficient information available currently, LPA will return to the facility on a later date to continue investigations into this matter.

An exit interview was conducted, LPA Giese provided Facility Director with a copy of this report and a notice of site visit. Notice of site visit must be displayed in a prominent location for the next 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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 1