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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425148
Report Date: 05/26/2023
Date Signed: 05/30/2023 12:18:33 PM

Document Has Been Signed on 05/30/2023 12:18 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL HALBROOKFACILITY NUMBER:
336425148
ADMINISTRATOR:CHARLES FISHERFACILITY TYPE:
735
ADDRESS:8124 HALBROOK TERTELEPHONE:
(951) 681-3614
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY: 4CENSUS: 3DATE:
05/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Rebecca Montoya, LPTTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit regarding an adult death of client #1 (C1), LPA Prieto met with LPT Rebecca Montoya who was at the facility at the time 911 was called to take C1 to the hospital. Montoya provided copies of C1's resident's records. LPA was also provided with the Death Report and Unusual Incident report that attempted faxed to the Licensing office on 05/25/2023 and received at the Licensing office on 05/26/2023. Facility staff was not yet told what was the cause death, but will email the results once known. LPA Prieto an Montoya signed and a this report and a copy was left at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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