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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600640
Report Date: 10/01/2024
Date Signed: 10/01/2024 03:30:27 PM

Document Has Been Signed on 10/01/2024 03:30 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL ROSEMEADFACILITY NUMBER:
198600640
ADMINISTRATOR/
DIRECTOR:		JOHNSON, JUSTINFACILITY TYPE:
735
ADDRESS:1702 ROBIN LINDA LNTELEPHONE:
(626) 927-9177
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
10/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:43 PM
MET WITH:Justin Johnson, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:44 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) Alberto Lopez made an unannounced meeting to follow up on Regional Center inspection visit dated 07/10/2024. LPA met with Administrator Justin Johnson and discussed the purpose of the visit.

LPA reviewed and obtained copy of staff and client rosters.

LPA took tour of facility and inspected the following:

1) Knifes were stored in the same area as chemicals.
LPA observed that the knifes are now stored separate from the chemicals.

2) Staff require training on reporting requirements.
All staff received training on reporting requirements and LPA reviewed and obtained proof.


All deficiencies have been corrected as of today's visit.

No deficiencies observed during visit.

Exit interview, copy of report, and appeal rights provided to Administrator Justin Johnson
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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 1