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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800303
Report Date: 10/24/2024
Date Signed: 10/24/2024 10:55:30 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/27/2024 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240627105431
FACILITY NAME:COLE VOCATIONAL SERVICES AUTO CENTERFACILITY NUMBER:
565800303
ADMINISTRATOR:LISA LOPEZFACILITY TYPE:
775
ADDRESS:2011 AUTO CENTER DR STES 106-7TELEPHONE:
(805) 278-2700
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:60CENSUS: 42DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jesus CardenasTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision: Client #1 (C1) sustained burns to their feet while in care.
Neglect/Lack of Care and Supervision: Staff #1 (S1) left Client #1 (C1) in soiled diapers.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegations. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA met with Program Director Jesus Cardenas and explained the reason for the visit. Administrator Lisa Lopez was away conducting training during the visit.

On 06/27/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding Neglect/Lack of Supervision of Client #1 (C1) while at the day program facility. C1 sustained burns to the bottom of their feet while under the supervision of C1’s one-to-one Staff #1 (S1). The complaint also alleged C1’s diaper was soiled and wet. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Olivia Spindola.

(continued on LIC9099C, page 2)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20240627105431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COLE VOCATIONAL SERVICES AUTO CENTER
FACILITY NUMBER: 565800303
VISIT DATE: 10/24/2024
NARRATIVE
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(continued from LIC9099, page 1)

On 07/03/2024, from 9:00 a.m. to 1:03 p.m., LPA T. Camara conducted an initial complaint investigation visit. Tri-Counties Regional Center (TCRC) Quality Assurance Specialists (QAS) Liz Aced-Arnett and QAS Patrick Brown were also present during the visit. Interviews were conducted with several staff between 9:16 a.m. and 11:51 a.m. Record review and obtaining pertinent documents started at 10:13 a.m.

On 07/17/2024, at approximately 11:00 a.m., Investigator Spindola conducted an interview with C1’s client representative; on 08/05/2024, from approximately 11:00 a.m. to 12:00 p.m., with C1’s client representative and witnesses; on 08/16/2024, at approximately 9:20 a.m., with C1’s respite worker; on 08/20/2024, from approximately 12:00 p.m. to 2:00 p.m., with the facility manager/administrator, supervisor, and staff; on 09/24/2024, from approximately 10:00 a.m. to 5:30 p.m., with S1 and C1’s respite worker; and on 09/27/2024, at approximately 11:00 a.m., with C1’s client representative. In addition, the investigator reviewed Community Memorial Hospital (CMH) Ojai medical records, Clinicas Del Camino Real Ojai Health Center medical records, facility internal investigation report, photos of C1’s injuries, and facility file documents pertinent to C1 and the investigation.

A review of the Department of the Developmental Services (DDS) client evaluation report, dated 10/16/2023, documented C1’s diagnosis as moderate intellectual disability, epilepsy, requires constant supervision during waking hours to prevent injury/harm in all settings, not toilet trained, no control of bladder or bowel, non-verbal, uses wheelchair, walks alone 10 feet, but unsteady.

According to C1’s pre-admission physicians report, dated 06/07/2024, C1 required help with dressing, personal hygiene, toileting, using the bathroom, incontinent, and required assistance with eating sometimes. Communication was listed as non-verbal communicates by using sounds and movements. The report also listed C1 had a diagnosis of cerebral palsy, developmental issues, history of seizures, muscular atrophy, can walk with support, and uses stroller.


(continued on LIC9099C, page 3)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20240627105431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COLE VOCATIONAL SERVICES AUTO CENTER
FACILITY NUMBER: 565800303
VISIT DATE: 10/24/2024
NARRATIVE
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(continued from LIC9099, page 2)

The facility individual profile, dated 06/10/2024, documented C1’s diagnosis as cerebral palsy, moderate intellectual disability, pica and seizure disorder. The profile indicated C1 needed toileting and changing of diapers, walks some on own, needs assistance, and uses a stroller wheelchair or wheelchair for outings. According to the administrator, C1 began receiving services at the day program facility on 06/13/2024. C1 initially received services by phone then first came to the facility on 06/17/2024. C1 came to the facility Mondays, Wednesdays, and Fridays.

A review and summary of the Community Memorial Hospital (CMH) Ojai medical records revealed on 06/26/2024, C1 was treated for chief complaint of burns to feet. “Patient has secondary burns to the soles of bilateral feet. Patient does have a history of developmental delays and cerebral palsy. These occurred while the patient was at daycare, has blisters to both feet, second-degree burns with blisters to the bilateral soles of the feet.”

On 06/28/2024, C1 received follow up care from the Clinicas Del Camino Real Ojai Health Center. The medical records document in part, “ER follow up…returning today for evaluation of wounds/burns on feet bilaterally. Physical Exam…Left foot - patient with an un-roofed 2nd degree burn over the ball of the foot. Underlying tissue is red and healing well. No signs of necrosis or infection. Longest length of the burn is 7 cm. Patient also as a burn on the heel of the foot which is consistent with walking on a hot surface. That burn is still with the epidermal layer covering the side of the burn. Right foot - patient with a 2nd degree burn over the ball of the foot on the right. Skin is overlying the ball of the foot, and the dermal layer is covered. Diameter of this burn is 3 cm…”

The Department’s investigation revealed that on 06/26/2024, at 8:15 a.m., C1’s client representative dropped off C1 at the facility and picked up C1 at 2:00 p.m. C1’s one-to-one staff, S1, rolled C1 on their adult stroller from the facility’s front entrance where they had been waiting for a half an hour for C1’s client representative’s van. S1 placed the stroller one to four feet from the van parked behind the three handicap

(continued on LIC9099C, page 4)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20240627105431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COLE VOCATIONAL SERVICES AUTO CENTER
FACILITY NUMBER: 565800303
VISIT DATE: 10/24/2024
NARRATIVE
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(continued from LIC9099C, page 3)

spaces by the front entrance. C1’s client representative had to park the van blocking the handicap spaces due to Cole Corporation of Camarillo staff having a meeting at the facility, thus occupying all the facility’s parking spaces. S1 assisted C1’s client representative to unbuckle C1 from their stroller’s restraints. C1 stood up at which time C1’s client representative checked C1’s diapers to ensure C1 was dry for their trip home. At that point C1’s client representative confronted S1 about C1 having a dirty diaper and not wearing shoes or socks. S1 replied, “I had to choose my battles, C1 didn’t want to wear their shoes and C1 didn’t let me take them to the restroom to change C1.” C1’s client representative noticed C1 hopping when C1 took a couple steps from the stroller to the van. C1’s client representative placed a sweater on the van seat then buckled C1 using the van’s seatbelt. C1’s client representative and other witnesses in the van stated C1 whined, cried, and bit C1’s hands on the way home. Upon arrival at home, C1’s respite worker met C1 and discovered that the bottom of C1’s feet were raw, and the top skin layer was gone. C1’s diaper and clothing were then changed and C1’s client representative obtained medical care for C1 at Community Memorial Hospital Ojai (CMH) where C1 was diagnosed with second degree burns to both feet. In addition, information obtained from the facility internal investigation report noted that on 06/26/2024, the outside temperature in Oxnard was 71 degrees, and 125 degrees Fahrenheit on the asphalt.

Based on C1’s feet injuries, S1 and facility staff statements indicating that S1 allowed C1 to be shoeless most of the day indoors and outdoors during a hot day, and the statement by S1 that they did not change C1’s diapers during that day, the Department concluded there was sufficient evidence to substantiate both the allegations of Neglect/Lack of Supervision. Therefore, the allegations “Client #1 (C1) sustained burns to their feet while in care” and “Staff #1 (S1) left Client #1 (C1) in soiled diapers” are deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Program Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1548(f)(1)(B)(ii).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240627105431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COLE VOCATIONAL SERVICES AUTO CENTER
FACILITY NUMBER: 565800303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
82078(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.
This requirement is not met as evidenced by:
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Licensee will submit a plan how staff will provide care and supervision to meet the individual needs of the clients. Submit to CCL by 10/31/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above. S1 allowed C1 to be shoeless during a hot day, resulting in second degree burns to feet, which posed an immediate health and safety risk to clients in care.
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Type A
10/31/2024
Section Cited
CCR
82077.4(b)(4)
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82077.4Care for Clients with Incontinence
(b) If a licensee accepts/retains a client who has bowel and/or bladder incontinence, the licensee is responsible for all of the following:(4)Ensuring that a client is kept clean and dry, and that the day program remains free of odors.
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Licensee will submit a plan how they will ensure clients are kept clean and dry while at program. Submit to CCL by 10/31/2024.
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This requirement is not met as evidenced by:Based on interviews and records review, the licensee did not comply with the section cited above. S1 allowed C1 to remain in soiled diaper throughout the day program hours, which posed an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/27/2024 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240627105431

FACILITY NAME:COLE VOCATIONAL SERVICES AUTO CENTERFACILITY NUMBER:
565800303
ADMINISTRATOR:LISA LOPEZFACILITY TYPE:
775
ADDRESS:2011 AUTO CENTER DR STES 106-7TELEPHONE:
(805) 278-2700
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:60CENSUS: 42DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jesus CardenasTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff was smoking in front of the client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegation. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA met with Program Director Jesus Cardenas and explained the reason for the visit. Administrator Lisa Lopez was away conducting training during the visit.

On 7/3/2024, LPA conducted interviews with five staff. All noted the smoking area for the facility is at the corner of the parking lot. None of the staff had observed Staff 1 (S1) or any other staff smoke in front of non-smoking clients. All staff find coverage for clients before leaving for a smoke break. LPA observed staff on that day smoking in that area. Clients who smoke also go to that area with staff. During today's visit, LPA also observed staff taking a smoke break in that area.

Based on interviews and observation, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and report issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6