<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850062
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:33:19 PM

Document Has Been Signed on 12/09/2022 01:33 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: 18DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Jesus CardenasTIME COMPLETED:
01:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 12:05 p.m. The LPA met with Jesus Cardenas and explained the reason for the visit. There are seventeen (17) consumers and seven (7) program staff present today. The program currently operates from 9:00 a.m. to 2:00 p.m. The day program was staffed with 1:3 staff to consumer ratios. Temperatures of staff and consumers are taken upon entry into the facility.

Common Activity Space: The facility is a single-story structure with several activity rooms, a conference room, five (5) bathrooms, offices, and a food service area. The LPA did not observe any obstructions or hazards. Activities: Activities are both designed for individual and as a group. The LPA observed staff working with consumers. Food Service: The kitchen area was clean and in good condition. Consumers bring their lunch and snacks. Restrooms: Restrooms were clean and sanitary. The LPA recommended the facility place hand washing signs in all restrooms. The LPA observed disinfectant wipes in the cabinet of all five (5) bathrooms and disinfectant spray in one (1) of five (5) bathrooms. These items were secured upon observation. Water temperature measured at 106.4 degrees F at 12:40 p.m. Files: At 1:00 p.m., the LPA checked staff associations and identified that Staff #1 (S1) had fingerprint clearance but was not associated to this location. However, S1 was associated during today’s visit.

Infection Control: There was a central entry point for symptom screening and temperature checks. The LPA was appropriately screened upon entry. Staff and consumers were wearing appropriate face coverings. Infection Control signs were observed on the front door and throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol was sufficient. The facility keeps record of staff and consumer vaccinations. The LPA discussed changes around testing, masking and vaccine requirements. The facility's procedures as it pertains to infection control are adequate.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties assessed. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/09/2022 01:33 PM - It Cannot Be Edited


Created By: Ashley Smith On 12/09/2022 at 01:19 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: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as disinfectant and wipes were observed accessible in five (5) bathrooms, which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
1
2
3
4
The Program Director agreed to do the following:
1. Items were secured upon observation. Plan of Correction met.
Type A
Section Cited
CCR
82019(e)(2)
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: (2) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above, as Staff #1 (S1) was not associated to this location, which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
1
2
3
4
The Program Director agreed to do the following:
1. S1 was associated during today's visit; proof of association provided. Plan of Correction met.
Civil penalties assessed at $100 per day, for a maximum of five days. Civil penalties assessed in the amount of $500.
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:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2