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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364844012
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:19:27 PM

Document Has Been Signed on 03/15/2024 03:19 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: 16CENSUS: 10DATE:
03/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:CLAVESILLA, ELVIATIME COMPLETED:
03:30 PM
NARRATIVE
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On 03/15/2024 at time listed above, Licensing Program Analyst (LPA) Justin Giese conducted an unannounced case management visit at the Facility for the purpose of concluding an investigation pertaining to the Facility's submission of an Unusual Incident Report (UIR) received by Licensing 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 was granted entry to the Facility and met with Facility Director, Elvia Clavesilla.

According to the UIR, a child was not obeying a Staff’s verbal instructions and refused climb down from the slide/play structure when asked. Staff continued to ask the child to climb down, after further instruction with no compliance, Staff carried/lifted the child from their location on the slide/play structure and set the child on the ground. Once on the ground, the child intentionally dropped down to the ground in refusal to leave the playground. Staff held onto the Child’s arm in an effort to lift them up to their feet and have them line up with other children to exit the playground. Due to staff holding the child’s arm and attempting to lift them up from the ground, the child sustained redness and markings on their inner left arm. UIR stated when the incident was reported to facility Director, an interview was conducted with the child who stated: “staff hurt my arm.” Facility conducted an internal investigation and placed the Staff member involved on administrative leave.

On 03/05/2024 LPA made an unannounced visit to the facility for the purpose of investigating the receipt of this UIR. LPA met with Facility Director, conducted an interview and collected/reviewed photos and documents related to this incident. LPA obtained an internal “ouchie” report detailing the Child’s injury, which was signed/acknowledged by the Child’s Authorized Representative. Additionally, LPA reviewed a written statement from staff involved, which corroborate events listed in the UIR. LPA observed three photographs of the Child’s injury. LPA observed noticeable redness/markings near the Child’s left inner-arm elbow area. LPA was informed by Director, the Staff member involved in this incident was terminated from employment.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PP
FACILITY NUMBER: 364844012
VISIT DATE: 03/15/2024
NARRATIVE
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As a result of the incident occurring and submission of the UIR to Licensing, the Facility held a staff training session on 02/29/2024 detailing personal rights of children in care. LPA obtained training materials and sign-in/attendance sheets with signatures for staff that received this training.

Based on LPA's interview, observation and evidence collected, its has been confirmed a Staff member inappropriately handed a child in care resulting in injury. The Facility was found to be in violation of the following Title 22 Regulation:

Personal Rights: 101223(a)(3)
101223 Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain...

See LIC809D for Type A deficiency Cited during this inspection

Exit interview conducted and report was reviewed with the Facility Director, Elvia Clavesilla.

LPA issued a Notice of Site Visit and verified it was posted in a prominent location at the facility. Director understands that the Notice of Site Visit must remain posted for the next 30 days along with a copy of all Type A deficiencies cited during this inspection. A copy of all Type A deficiencies cited during this inspection must also be immediately (within 24 hours of child’s next day in care) given to the parents of all children enrolled in the child care facility and any children enrolled into the child care facility over the next 12 months (at the time of enrollment). Licensees are required to have all parents sign and date the Acknowledgement of Receipt of Licensing Reports (LIC9224) and maintain a copy in each child’s file. A copy of this report (LIC809), Acknowledgement of Receipt of Licensing Reports (LIC9224) and Appeal Rights (LIC9058) were provided during this inspection.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/15/2024 03:19 PM - It Cannot Be Edited


Created By: Justin Giese On 03/15/2024 at 01:51 PM
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 ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: VOLUNTEERS OF AMERICA EHS CC PP
FACILITY NUMBER: 364844012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2024
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights: (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain...

This was not met as evidenced by:
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Facility Director understands the importance of children's personal rights while in care. Facility self reported the incident, documented with photos and terminated Staff involved. Facility director concucted staff training on 02/29/2024 regarding topics of family service and personal rights of children.
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Based on observation, interview and photos obtained, Facility self reported a Staff member inappropriately handed a child in care resulting in injury. This ia an immediate health and safety and personal rights risk to children in care.
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Documentation of this training and staff attendance was obtained by LPA on 03/05/2024 and will serve as proof of correction. POC will be cleared at time of this visit on 03/15/2024.

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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:Gilbert Sena
LICENSING EVALUATOR NAME:Justin Giese
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
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