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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005586
Report Date: 08/12/2021
Date Signed: 09/10/2021 11:22:33 PM

Document Has Been Signed on 09/10/2021 11:22 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:COLE VOCATIONAL SERVICES MODESTOFACILITY NUMBER:
507005586
ADMINISTRATOR:MADSEN, TAMARAFACILITY TYPE:
775
ADDRESS:544 LYELL DRTELEPHONE:
(209) 575-3100
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 90CENSUS: DATE:
08/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lisa BartleyTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facilities annual inspection. LPA met with Program Director Lisa Bartley There are currently 41 who receive in person services at this facility. LPA inspected the interior and the exterior of the facility including the activity rooms, and all common areas. Facility was clean and in good repair.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 105.0 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator and copy of report left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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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