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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801293
Report Date: 12/15/2023
Date Signed: 12/15/2023 05:48:08 PM

Document Has Been Signed on 12/15/2023 05:48 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COLE VOCATIONAL SERVICES EASTMANFACILITY NUMBER:
565801293
ADMINISTRATOR:CATARINA GARCIAFACILITY TYPE:
775
ADDRESS:2363 EASTMAN AVETELEPHONE:
(805) 658-9300
CITY:VENTURASTATE: CAZIP CODE:
93001
CAPACITY: 45CENSUS: 18DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Iokany Parra-TIME COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez arrived at the Adult Day Program (ADP) unannounced to conduct a required annual visit at 11:15 a.m. The LPA met with Program Director Iokany Parra and explained the reason for the visit. The program currently operates from 8:00 a.m. to 2:00 p.m. The day program was staffed with 1:1 staff to consumer ratios and with one group of 1:3 staff to consumer ratio.

Record Review: At 11:30 a.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and last fire drill (conducted on 05/31/2023. The LPA obtained Client Roster, Staff Roster, and Staff schedule. The LPA reviewed five (5) of eight-teen (18) Client Files. One out of five client files (C1) did not have an admissions agreement, and one out five clients did not have a medical assessment with Tuberculosis test results. The LPA reviewed five (5) out of thirteen (13) staff files. All staff documents reviewed appeared complete and current.
Infection Control: Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility's procedures as it pertains to infection control are adequate.
Interview: During today's visit, the LPA interviewed three (3) staff and three (3) consumers. No immediate concerns voiced at this time.
Medication Audit: A medication audit for two (2) clients was initiated at 3:15 p.m. and the following was observed. Medications are centrally stored and locked in a locked cabinet in the Program Directors office; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. The LPA observed both clients have PRN medications, and the Day Program does not have a PRN Authorization Letter on file for one out two consumers, to indicate whether the consumer is able to make their own decision or if the doctor needs to be contacted prior to assisting the residents with the PRN medications. Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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Document Has Been Signed on 12/15/2023 05:48 PM - It Cannot Be Edited


Created By: Esther Cortez On 12/15/2023 at 05:00 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COLE VOCATIONAL SERVICES EASTMAN
FACILITY NUMBER: 565801293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out five (C1) consumers which poses a potential health and safety risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Program Director agrees to obtain Admissions agreement for C1 and submit proof to CCL by no later than POC due date.
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of five consumers (C2) which poses a potential health and safety risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Program Director will request TB results for C2 and submit test results to CCL by no later than 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2023 05:48 PM - It Cannot Be Edited


Created By: Esther Cortez On 12/15/2023 at 05:00 PM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COLE VOCATIONAL SERVICES EASTMAN
FACILITY NUMBER: 565801293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82075(b)(5)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, program staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of two consumers (C3) who are prescibed PRN medications and no PRN autherization letters were on file which poses a potential health and safety risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Program Director agrees to obtain signed PRN letters that indicate if the clients are able or unable to determine their own need for PRN medications and specify the PRN medication or if their doctor needs to be contacted prior to administering the PRN medication and submit Proof to CCL 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COLE VOCATIONAL SERVICES EASTMAN
FACILITY NUMBER: 565801293
VISIT DATE: 12/15/2023
NARRATIVE
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At 03:41 p.m., the LPA and the Program Director Iokanny toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The smoke alarms and carbon monoxide detectors were tested during the visit and functioned properly.

Common Activity Space: The facility is a single-story structure with one decompression room, Arts & Crafts room, music room, activity room, resource room, exercise room, changing room, training room, sensory room, computer room, two offices, three bathrooms, and a food service area. The LPA did not observe any obstructions or hazards during the inspection. The program site appeared to be clean, safe, sanitary, and in good repair at this time. The LPA observed fire extinguishers throughout the facility, which were last serviced 12/14/2023.

Activities: Activities are both designed for individual and as a group. The LPA observed activity supplies in most rooms.

Food Service: The kitchen areas were clean and in good condition. Consumers bring their lunch and snacks. The facility has snacks and water available for consumers.

Restrooms: The three restrooms were observed to be clean and sanitary with a hand soap and paper towels. The hot water temperature in one of the restrooms was tested at 3:55 p.m., and it measured at 120.0 degrees Fahrenheit. A conversation was held with the Program Director to ensure the water temperature does not exceed 120 degrees.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and copy of the report and appeal rights provided to the Program Director.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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