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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803590
Report Date: 10/30/2023
Date Signed: 10/30/2023 11:33:24 AM

Document Has Been Signed on 10/30/2023 11:33 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: 17DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Holly Charlton (Administrator)TIME COMPLETED:
11:48 AM
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Licensing Program Analyst Cuadra arrived unannounced to conduct an Annual Required inspection and met with Administrator, Holly Charlton. Required postings were observed.

LPA/staff initiated tour of the facility and observed the following: Facility has a large open area as well as pocket areas for different activities in addition to three changing rooms, administrative offices, a quiet room, three bathrooms, kitchen and a dining area. Toxins are stored in various locked closets/storage rooms. One locked storage room containing cleaning supplies near the washer and dryer. Medications are centrally stored in the nurses office. A refrigerator is located in the kitchen to accommodate client lunches and snacks. There are lockers for client's personal items. Water temperature in bathroom read at 107.1 which is within regulation of 105 and 120 degrees F. Clients were participating in a variety of activities at the time of visit.

Fire extinguishers are fully charged and were last serviced January 2023. 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. Last disaster drills was conducted 10/19/2023. Program does not provides transportation. Medications & records were reviewed. One Licensed Vocational Nurses is at facility whenever clients are present.

File review was initiated at 9:00am. Five staff files and ten participant files were reviewed. Staff records included a health screen and TB test, criminal record clearance and required training hours. However, 3 out of 5 staff (S1, S2 & S3) did not have current First Aid/CPR training on file. 9 out of 10 participants (P2 through P10) files did not have medical assessments on file and 4 out of 10 participants (P1, P5, P6 & P7) needs and services plan were not updated within the last 12 months as stated per regulation.

Continue on LIC 809C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: COLE VOCATIONAL SERVICES SANTA ROSA
FACILITY NUMBER: 496803590
VISIT DATE: 10/30/2023
NARRATIVE
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Continued from LIC809

LPA has requested updates copies of the following documents be submitted to CCL by 11/20/2023: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610), copy of Liability Insurance Certificate and copy of current lease agreement.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2023 11:33 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/30/2023 at 11:12 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COLE VOCATIONAL SERVICES SANTA ROSA
FACILITY NUMBER: 496803590

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with Administrator, the licensee did not comply with the section cited above in 4 out of 10 participant's care plans were not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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Administrator agrees to have participant's care plans updated and will send a self-certification form (LIC9098) by POC due date.
Type B
Section Cited
CCR
82069(b)
Client Medical Assessments
(b) The medical assessment shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with Administrator, the licensee did not comply with the section cited above in 9 out of 10 participant's medical assessments were not on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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Administrator agrees to have participant's medical assessments on file and will send a self-certification form (LIC9098) by POC due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/30/2023 11:33 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/30/2023 at 11:12 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COLE VOCATIONAL SERVICES SANTA ROSA
FACILITY NUMBER: 496803590

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records and interview with Administrator, the licensee did not comply with the section cited above in 3 out of 5 staff did not have their CPR/1st aid current, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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Administrator agrees to have staff updated CPR/1st aid current and will send a self-certification form (LIC9098) 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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
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