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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850062
Report Date: 01/28/2022
Date Signed: 01/28/2022 12:33:27 PM

Document Has Been Signed on 01/28/2022 12:33 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:COLE VOCATIONAL SERVICES - SIMI VALLEYFACILITY NUMBER:
565850062
ADMINISTRATOR:CONK, SUSANFACILITY TYPE:
775
ADDRESS:660 EAST LOS ANGELES AVE UNT LTELEPHONE:
(805) 479-2604
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 45CENSUS: 2DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:April Amado, Day Program ManagerTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Salia Walker and Elsie Campos conducted an unannounced Required 1 Year inspection. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Day Program Manager April Amado at 9:57 a.m., and explained the reason for the visit. There are currently 2 clients attending the program.

The LPAs conducted a physical plant tour with April Amado at 10:02 a.m., to ensure there are no health and safety hazards. The facility consists of multiple rooms with activities for the clients to participate in. These rooms include a sensory room, computer lab, kitchen/breakroom area, juice room, fitness room, music room/ game room, arts and craft area, volunteer/ community area, and a rest area. The rest area/ resting room is also being used as an isolation room in the event of COVID-19 exposure in the facility.
Disinfectants and cleaning supplies are stored in the facility’s storage room. First aid supplies had required items. The facility has five (5) client restrooms, one (1) of which includes a shower. Between 10:05 a.m. and 10:22 a.m., hot water temperatures measured between 105.4 and 114.3 degrees Fahrenheit in the facility bathroom(s), and kitchen. The restrooms were observed to be clean, sanitary and in operating condition with hand soap, and toilet paper. The food service area was observed. At 10:06 a.m., the LPAs observed the facility’s kitchen trash bin cabinet door off the hinges. The Day Program Manager stated the repairs will be made to the cabinet door as soon as possible. The clients bring their own lunch, and snacks to the program. Medications are stored in a locked cabinet in the LVN's office.
The Day Program Manager advised the LPAs that facility landlord has all information of when the fire alarm system and pull stations were last serviced; date unknown at this time. The LPAs observed two (2) fire extinguishers last serviced on July 1, 2020. The Day Program Manager stated the facility’s Director was advised, and the facility will be contacting LAFD for a service request. The carbon monoxide detector was tested at 11:11 a.m., and was operational.
Continued on LIC 809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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: COLE VOCATIONAL SERVICES - SIMI VALLEY
FACILITY NUMBER: 565850062
VISIT DATE: 01/28/2022
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INFECTION CONTROL: During today’s visit, the LPAs spoke with the Day Program Manager regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is 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 does not have a confirmed case of COVID-19 at this time and the LPAs reviewed facility’s policies and procedures as it pertains to infection control. During today's visit, the LPAs conducted a record review. Record review revealed that one (1) out of four (4) facility staff is not associated and finger print cleared to this facility.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil Penalties assessed. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/28/2022 12:33 PM - It Cannot Be Edited


Created By: Salia Walker On 01/28/2022 at 12:05 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 - SIMI VALLEY
FACILITY NUMBER: 565850062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82020
82020 Fire Clearance All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing
fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, and interivews, the licensee did not comply with the section cited above in two (2) out of two (2)fire extinguishers are expired with an annual maintenance service date of 07/01/2020, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2022
Plan of Correction
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The Licensee has agreed to do the following:
1. Submit proof of newly serviced date or purchased Fire Extinguishers.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2022 12:33 PM - It Cannot Be Edited


Created By: Salia Walker On 01/28/2022 at 12:14 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 - SIMI VALLEY
FACILITY NUMBER: 565850062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following:

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 as one (1) out of four (4) facility staff is not associated and finger print cleared to the facility., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2022
Plan of Correction
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The Licensee has agreed to do the following:
1. Ensure that S1 is associated to the facility prior to allowing S1 to return to work. S1 will not work at the facility until proof of association is obtained.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022


LIC809 (FAS) - (06/04)
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