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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801424
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:40:20 PM

Document Has Been Signed on 01/16/2024 02:40 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ARC VC-COCHRANFACILITY NUMBER:
565801424
ADMINISTRATOR:KARIE RAGANFACILITY TYPE:
775
ADDRESS:5143 COCHRAN STREETTELEPHONE:
(805) 520-0399
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 90CENSUS: 56DATE:
01/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joseph LaporteTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced case management visit at 2:00 p.m. The purpose of this visit is to conclude an investigation regarding an incident that occurred on 12/11/2023. Upon arrival, LPA met with Program Director, Joseph Laporte and Case Manager Brianne Esseff and the reason for the visit was explained. Entrance Interview.

On 12/11/2023, the Department received an incident report stating on the afternoon of 12/11/2023, Staff #1 (S1) reported that Staff #2 (S2) had pushed and slapped Client #1 (C1) after C1 had lightly touched S2 on their side. S1 stated that C1 had lightly touched S2 to get their attention, S2 pushed C1 away and backed up before slapping C1 on their hand and yelling at C1 to not touch them. S1 immediately told S2 that they could not to that and S2 was seen storming out of the room upset.

During the initial visit on 12/19/2023, LPA Arroyo conducted interviews with five staff and one client between 1:50 p.m. and 3:27 p.m., conducted a resident file review at 2:40 p.m., and obtained copies of pertinent documents relevant to the investigation.

(Report Continued on LIC 809...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARC VC-COCHRAN
FACILITY NUMBER: 565801424
VISIT DATE: 01/16/2024
NARRATIVE
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(Report Contined from LIC 809...)

Interviews conducted revealed that there were three (3) additional staff members inside the room at the time of the incident along with S2 and C1. Staff interviews conducted separately corroborated with similar statements stating S2 had slapped C1’s hand away as C1 was approaching S2 in an attempt to get a hug. Upon feeling C1’s hand, S2’s initial reaction was to slap C1’s hand away as S2 yelled at C1 not to touch them. Furthermore, C1’s family was notified of the incident the same day and declined to press charges against S2 as S2 had been terminated from the day program following the incident. Based on the information obtained and reviewed, the Department has enough evidence to say that S2 slapped C1 while at the day program.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit.

Exit Interview conducted. Copy of report, and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 02/26/2024 08:51 AM


Created By: Martha Arroyo On 01/16/2024 at 02:17 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARC VC-COCHRAN
FACILITY NUMBER: 565801424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2024
Section Cited
CCR
82072(a)(3)

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82072(a)(3) Personal Rights (a)...each client shall have personal rights which include, but are not limited to, the following:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule.... This requirement is not met as evidenced by:
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The Licensee has agreed to conduct an in-house training on clients’ personal rights and submit proof to CCL no later than 01/19/2024.
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Based on interviews, the licensee did not comply with the section above as interviews revealed S2 slapped C1 while at the day program, which poses an immediate safety risk to clients 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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
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