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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601162
Report Date: 11/25/2024
Date Signed: 11/25/2024 09:52:38 AM

Document Has Been Signed on 11/25/2024 09:52 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SOCIAL VOCATIONAL SERVICES INC (SSF)FACILITY NUMBER:
415601162
ADMINISTRATOR/
DIRECTOR:		NAVARRO, CZARINAFACILITY TYPE:
775
ADDRESS:192 BEACON STREETTELEPHONE:
(650) 877-7255
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 60CENSUS: DATE:
11/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
10:10 AM
NARRATIVE
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On 11/25/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit to follow up on an incident that was reported to CCLD on 11/21/24. LPA met with Case Manager Edralyn JImenez and explained the purpose of the visit.

CCLD received report that at approximately 8:40am staff heard a client (C1) call out, "Help me, I tripped."
Staff (S1) approached C1, who was positioned on the floor on his/her knees and elbows, and observed bleeding around the mouth. S2 approached and assisted S1 to position C1 in a seated position on the floor with back against the wall. Staff assessed SM's injuries and observed a contusion on the forehead. Staff administered first aid and called 911. After arriving at the hospital and C1 has been assessed, hospital staff determined that C1 suffered broken bones in the neck and that surgery was needed. Surgery has been scheduled.

As of this report, surgery was scheduled and successful.

According to S3, there was no staff who was able to assist C1 while entering the back of the building. The 2 other staff that was with C1 when picked up in the home facility were also assisting other clients leaving C1 to enter on his/her own. While C1 doesn't like being assisted, there should have been a staff at least looking at C1 in case C1 needs help.

On C1s admission agreement it states that "the basic services that you will receive from SVS include planned activities, continuous supervision and assistance with your personal needs including self-medication if necessary."

Based on interviews and records review, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and a copy of this report and the appeal rights were provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 11/25/2024 09:52 AM - It Cannot Be Edited


Created By: Grace Donato On 11/25/2024 at 09:38 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SOCIAL VOCATIONAL SERVICES INC (SSF)
FACILITY NUMBER: 415601162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2024
Section Cited
CCR
92078(a)

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82078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.
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Licensee to submit a plan on how to address constant supervision of clients. Licensee to provide in-service training to staff. Licensee to submit POC plan by end of POC due date.
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This was not met as evidenced by: Based on interviews and records review, C1 sustained injuries due to lack of supervision of staff, which poses an immediate 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:Andrea Medlin
LICENSING EVALUATOR NAME:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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