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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803590
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:58:06 AM

Document Has Been Signed on 11/15/2022 11:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:COLE VOCATIONAL SERVICES SANTA ROSAFACILITY NUMBER:
496803590
ADMINISTRATOR:CHARLTON, HOLLYFACILITY TYPE:
775
ADDRESS:131-A STONY CIR STE 750TELEPHONE:
(707) 528-3771
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 60CENSUS: 24DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Holly Charlton - AdministratorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1 year infection control inspection and met with Program Manager Holly Charlton. Facility is currently providing alternative services to 24 participants through online activities and staff drop off activity packages including arts and crafts supplies for participants in average once a week.

LPA initiated tour of the facility with Program Supervisor at 10:40 am and observed the following: Facility has a large open area as well as pocket areas for different activities in addition to two changing rooms, administrative offices, a quiet room, four bathrooms, kitchen and a dining area. Toxins are stored in various locked closets/storage rooms. One storage room containing cleaning supplies near the washer and dryer was locked. Medications are centrally stored in the nurse’s office. A refrigerator is located in the kitchen to accommodate client lunches and snacks. Facility provides non-perishable foods used for snacks and cooking classes, when opened. There are lockers for client's personal items. Water temperature in bathroom read at 113.7 which is within regulation of 105 and 120 degrees F. Facility is not conducting in-person programs at this time. Anticipated reopen to in-person 1/1/2023.

Fire extinguishers are fully charged and were last serviced 1/4/22. Sprinklers and pull stations are located throughout the facility and are tested regularly by a vendor who contracts with the landlord. First aid kits were observed. Carbon monoxide detectors were present and working at the time of visit. Disaster drills are conducted monthly and the most recent was conducted 10/30/22. Program provides transportation. The facility currently does not provide transportation services, the transportation services are provided by R&D and different vendors. Required postings were observed.

Continue LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: COLE VOCATIONAL SERVICES SANTA ROSA
FACILITY NUMBER: 496803590
VISIT DATE: 11/15/2022
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Infection Controle:

Facility has submitted a mitigation program plan and Infection Control Plan. Facility has PPE supply stored in locked storage room. Staff had all PPE training required on file and have been N95 Fit Tested.



LPA reviewed Licensing Information System (LIS) with Program Manager/Administrator who informed it is correct at this time, nothing to be changed. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1st Aid certification for staff.

Administrator agreed to submit the following documents to CCL by 12/10/22:



Designation of Responsibility (LIC308)
Personnel Report (LIC500)

No deficiencies cited during today's visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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