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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409896
Report Date: 10/25/2024
Date Signed: 10/25/2024 03:56:14 PM

Document Has Been Signed on 10/25/2024 03:56 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KENNETH ADULT RESIDENTIAL IIFACILITY NUMBER:
366409896
ADMINISTRATOR/
DIRECTOR:		CHAVEZ, SYLVIAFACILITY TYPE:
735
ADDRESS:6818 BURKE CT.TELEPHONE:
(909) 628-0434
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 4DATE:
10/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Rosa Olibares, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 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 Eldin Serrano conducted an unannounced case management health and safety visit to this facility. Upon arrival LPA met with Assistant Administrator Rosa Olibares and discussed the purpose of the visit. LPA toured the facility and observed four (4) clients in care. There were no health and safety concerns observed. The facility was maintained at a comfortable temperature. LPA inspected the facility’s food supplies and observed it was adequate.

This health and safety visit is to check the welfare of the clients in care, and to inform the licensee that the licensing office has received information that the licensee filed a Chapter 11 bankruptcy effective date September 27, 2024. LPA informed the licensee about their responsibilities related to filing bankruptcy. A licensee of an adult residential facility must notify the city, county, department, residents, and their legal representatives in writing within two business days and inform new applicants and their representatives before admission. The licensee did not comply with the health and safety code 1562.2, this poses a potential health & safety risk to the clients in care.

The licensee was advised that an office meeting will be held on October 29, 2024 at 2:00PM, at the San Bernardino Regional Office at a future date.

Refer to LIC809D for deficiencies cited. An exit interview was conducted where this report, LIC809D, and appeal rights were discussed and provided to the licensee.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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 2
Document Has Been Signed on 10/25/2024 03:56 PM - It Cannot Be Edited


Created By: Eldin Serrano On 10/25/2024 at 03:42 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: KENNETH ADULT RESIDENTIAL II
FACILITY NUMBER: 366409896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
HSC
1562.2

1
2
3
4
5
6
7
(b) A licensee of an adult residential facility shall inform the city and county in which the facility is located, the department, all residents, and, if applicable, their legal representatives, in writing, within two business days, and shall notify all applicants for potential residence,
1
2
3
4
5
6
7
The licensee agreed to provide the Regional Office with copies of the bankruptcy filing, notice to the city and county, notice to Department, notice to the Residents/Responsible Parties, their legal representative if applicable as required by H&S 1562.2. within 15 days.
8
9
10
11
12
13
14
and, if applicable, their legal representatives, prior to admission, of any of the following events, or knowledge of the event:
(3) The licensee files for bankruptcy.
This requirement is not met as evidenced by: Based on the licensee did not inform the Department that the licensee filed Chapter 11 bankruptcy effective September 27, 2024.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


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