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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425347
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:50:08 PM

Document Has Been Signed on 01/29/2024 03:50 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KAISER ADULT BEHAVIORAL CENTER TEMECULAFACILITY NUMBER:
336425347
ADMINISTRATOR:SOUZA, SHARIFACILITY TYPE:
775
ADDRESS:27496 COMMERCE CENTER DR STE HTELEPHONE:
(951) 225-2632
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY: 60CENSUS: 26DATE:
01/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Shakilla WilliamsTIME COMPLETED:
04:00 PM
NARRATIVE
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On 1/29/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to address a deficiency observed during investigation of complaint control number 18-AS-20240123141432. LPA met with Administrator, Shakilla Williams who was informed of the purpose of the visit.

During the investigation, LPA was informed the incident regarding the complaint noted above was not reported to Community Care Licensing. The facility only reported the incident to Inland Regional Center and Adult Protective Services. Administrator Williams and Supervisor, Julietta Faelono reported the facility was unaware of Title 22, regulation 82061, Reporting Requirements. As a result, the facility will receive a Type B deficiency.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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Document Has Been Signed on 01/29/2024 03:50 PM - It Cannot Be Edited


Created By: Janette Romero On 01/29/2024 at 03:36 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KAISER ADULT BEHAVIORAL CENTER TEMECULA
FACILITY NUMBER: 336425347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2024
Section Cited
CCR
82061(a)

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In addition, a written report containing the information specified in Section 82061(a)(2) shall be submitted to the licensing agency within seven days following the occurrence of the event. This requirement was not met as evidenced by:
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Administrator Williams stated the facility will provide in-service staff training regarding reporting requirements. Proof of correction to be submitted to CCLD by close of business on POC due date.
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During investigation of complaint control number 18-AS-20240123141432, LPA was informed the facility did not report the incident regarding the complaint to CCLD. This poses a potential health and 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
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