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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423573
Report Date: 11/19/2021
Date Signed: 11/19/2021 12:09:36 PM

Document Has Been Signed on 11/19/2021 12:09 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
RIVERSIDE, CA 92507
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL SERRANOFACILITY NUMBER:
366423573
ADMINISTRATOR:REBA JORDANFACILITY TYPE:
735
ADDRESS:16146 SERRANO AVETELEPHONE:
(760) 242-5759
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 3DATE:
11/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Reba JordanTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a case management visit due to a recent death of a client at the facility. LPA Williams identified herself to Administrator, Reba Jordan, who was also advised of the purpose of the visit.

On November 17th 2021, the Department was notified of the death of Client #1 (C1). LPA Williams advised the Administrator that a death investigation for C1 has been assigned to the Department's Investigation's Branch. The Administrator was also advised that the assigned Investigator will return at a later date to conduct the investigation.

During today's visit, LPA Williams collected records that are pertinent to the investigation, including:
  • C1's Individual Program Plan (IPP) from Inland Regional Center & People's Care
  • C1's Physician's Report
  • C1's Last Physician Visit Notes
  • C1's Medication Administration Record (MAR)
  • C1's Admission Agreement
  • Incident Reports
  • C1's Emergency/Identification Information

LPA Williams also requested additional documentation be sent to the Department; such as, the Coroner's Report, Police Report, and a Death Certificate upon availability.

An exit interview was conducted where this report was discussed and a copy was provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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