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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427604
Report Date: 08/29/2023
Date Signed: 09/06/2023 08:29:26 AM

Document Has Been Signed on 09/06/2023 08:29 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COLE VOCATIONAL SERVICES HESPERIAFACILITY NUMBER:
366427604
ADMINISTRATOR:HIRES, SIMIENFACILITY TYPE:
775
ADDRESS:15075 MAIN STTELEPHONE:
(760) 998-2829
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 75CENSUS: 26DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Simien Hires-Program ManagerTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced required Annual Inspection. LPA met with Program Manager, Simien Hires. LPA was accompanied by Program Manager to conduct a general overall inspection, which included, but was not limited to, the following:

LPA inspected the facility inside and outside. LPA observed all passageways are clear of obstructions. The facility is maintained at a comfortable temperature of 75 degrees fahrenheit. LPA inspected client activity rooms; they are equipped with required furniture and activity supplies for clients. LPA inspected client bathrooms; bathroom appliances were operating in good and sanitary conditions. LPA observed grab bars in the bathrooms. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 109 degrees fahrenheit. Disinfectants, toxins, sharps and cleaning supplies are locked and inaccessible to clients. There are no firearms/ammunition or bodies of water.

At Day Program, clients are responsible to bring their own lunch. Snacks were accessible to clients and stored in a healthful manner. LPA observed the kitchen area to be clean, free of odors, and in a healthful manner.

LPA observed sufficient staff present for the number of clients in care. Day program does not administer medication and no medication is stored at the facility. LPA observed fire extinguishers, smoke alarms, carbon monoxide alarms, and first aid kit in the facility. The last fire drill was conducted on 8/14/23.

LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA observed the (C1) signature missing on the personal rights. Technical violation issued. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed (S1) missing orientation, employee rights and suspected abuse reporting from staff's file. Deficiency issued. LPA also observed criminal background transfer clearance missing for (S1). Deficiency with civil penalty issued.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: COLE VOCATIONAL SERVICES HESPERIA
FACILITY NUMBER: 366427604
VISIT DATE: 08/29/2023
NARRATIVE
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Based on the observations made during today’s visit, two deficiencies, one technical violation and one civil penalty were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIC809C, LIC9102TV, LIC809D, LIC421BG and appeal rights were discussed and provided to Program Manager, Simien Hires.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/06/2023 08:29 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/29/2023 at 11:24 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COLE VOCATIONAL SERVICES HESPERIA
FACILITY NUMBER: 366427604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the program manager did not comply with the section cited above by maintaining the personnel records incomplete with missing information which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Program manager states that he will review regulation 82066(a) and provide the missing orientation, employee rights and suspected abuse reporting for S1's record to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/06/2023 08:29 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/29/2023 at 11:43 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COLE VOCATIONAL SERVICES HESPERIA
FACILITY NUMBER: 366427604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the program manager did not comply with the section cited above in requesting a criminal record clearance transfer for (S1) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2023
Plan of Correction
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Program Manager requested criminal record clearance transfer for (S1) along with adding staff on the facility's guardian roster and provided proof to LPA on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
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