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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423573
Report Date: 07/21/2023
Date Signed: 07/21/2023 12:15:57 PM

Document Has Been Signed on 07/21/2023 12:15 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 SERRANOFACILITY NUMBER:
366423573
ADMINISTRATOR:REBA JORDANFACILITY TYPE:
735
ADDRESS:16146 SERRANO AVETELEPHONE:
(760) 242-5759
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
07/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Elizabeth GonzalezTIME COMPLETED:
12:25 PM
NARRATIVE
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On 07/21/2023 at 9:00 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct a Case Management Deficiency. LPA Brown was greeted and granted entrance by Administrator Elizabeth Gonzalez. LPA Brown identified herself and discussed the purpose of the visit and the elements of the allegation with Administrator Elizabeth Gonzalez.

During the facility visit, LPA Brown toured the facility and observed that Staff #2 (S2) had been working at the facility, listed on staff schedule with criminal record clearance but not associated to the facility. Administrator Gonzalez confirmed with LPA Brown that S2 had been working at the facility since 03/23/2023. LPA Brown informed Administrator Gonzalez that S2 must be associated to the facility and deficiency will be issued as this pose potential safety risks to clients in care.

Civil penalty was assessed with the amount of $500.00 during the facility Visit for failure to associate/transfer S2 Criminal Record Clearance to the facility.

An exit interview was conducted where this report, LIC809, LIC809D, LIC421BG and Appeal Rights were discussed and provided to Administrator Elizabeth Gonzalez.


SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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 07/21/2023 12:15 PM - It Cannot Be Edited


Created By: Melody Brown On 07/21/2023 at 11:40 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
, CA 92507

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working...2) Request a transfer of a criminal record clearance...This requirement is not met as evidenced by:
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Licensee stated to associate Staff #2 at the facility and submit proof of association to the facility to LPA Brown by POC due date.
Licensee stated to submit signed Statement of Understanding on CCR 80019(e)(2) and submit to LPA Brown by POC due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by not transferring Staff #2 criminal record clearance prior to allowing S2 to work at the facility which pose potential health, safety and personal rights risks 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
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