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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423573
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:03:54 AM

Document Has Been Signed on 10/27/2023 11:03 AM - 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, 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: 4DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Elizabeth Gonzalez- DSPTIME COMPLETED:
11:10 AM
NARRATIVE
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On 10/27/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with DSP, Elizabeth Gonzalez and introduced self and stated purpose of the visit. LPA was informed that there are 3 clients at home and one in program.

The facility has 4 bedrooms, 3 bathrooms, kitchen, pantry, dining area, living room, family room, office, laundry, backyard, and attached garage. LPA completed a walk through of facility, and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 111.9 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, disaster plans and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. LPA observed detergent unlocked and accessible to clients while staff walked away from laundry room. Deficiency issued. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no swimming pool or bodies of water in the facility. There are no firearms or ammunition in the facility. LPA observed the wall behind the recliner in the family room damaged by the recliner. Technical violation. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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Document Has Been Signed on 10/27/2023 11:03 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/27/2023 at 10:22 AM
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 SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the DSP did not comply with the section cited above in making the detergent in the laundry room inaccessible to clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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DSP states that a training on regulation cited will be held with staff and an attendance sheet with signatures will be sent to LPA via email by POC due date.
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the DSP did not comply with the section cited above in making P & I available for audit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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DSP states that statement of understanding on regulation cited will be submitted to LPA via email by POC due date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573
VISIT DATE: 10/27/2023
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Yards/Outside: One shaded patio, side gate with self-latching handle in the front of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed administrator and DSP files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed two client files for admission agreements, updated physician reports, and needs and services plans. P & I funds was not available for audit due to keys not being available. Deficiency issued. LPA reviewed facility's file for fire drills and infection control plan.

Deficiencies and technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to DSP, Elizabeth Gonzalez.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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