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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402294
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:20:19 PM

Document Has Been Signed on 10/03/2024 02:20 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COLE VOCATIONAL SERVICES VICTORVILLEFACILITY NUMBER:
366402294
ADMINISTRATOR/
DIRECTOR:		COX, BRANDONFACILITY TYPE:
775
ADDRESS:16519 VICTOR STTELEPHONE:
(760) 962-9111
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 120CENSUS: 97DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Natalie Boubion-Program SupervisorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced case management visit to follow up on an incident report sent to licensing dated on 07/12/24. LPA was greeted and explained the reason for the visit to Program Supervisor, Natalie Boubion.

Per the incident report, a client was left unattended for 12 minutes by their designated supervising staff at a public mall. During today's visit, it was discovered that Cole Vocational Services Victorville investigated the incident and terminated the staff on 8/2/24.

One deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were discussed and provided to Program Supervisor, Natalie Boubion.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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 10/03/2024 02:20 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/03/2024 at 01:44 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COLE VOCATIONAL SERVICES VICTORVILLE
FACILITY NUMBER: 366402294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2024
Section Cited
CCR
82065.1(a)(1)

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82065.1(a)(1) Personnel Qualifications and Duties
(a) The following requirements shall apply to direct care staff as defined in Section 82001(d): (1) Direct care staff shall be responsible for care and supervision... Section 82001(c). This requirement was not met as evidenced by:
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Program Supervisor stated that the Administrator conducted a refresh training on mandatated reporting and supervision on 7/25/24. A copy was provided to LPA. POC cleared.
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Based on interview and record review, the Administrator did not comply with the section cited above by not having responsible direct staff for care and supervision which 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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