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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423573
Report Date: 10/11/2023
Date Signed: 10/11/2023 10:01:35 AM

Document Has Been Signed on 10/11/2023 10:01 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
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:
10/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Ernest Montes, AdministratorTIME COMPLETED:
10:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at facility for a Case Management Visit. LPA met with Administrator Ernest Montes. Purpose of visit was to present licensee with findings following the Department investigation of the death of C1.

On November 17, 2021, the licensee reported to the Department that C1 was absent without leave (AWOL) from the facility. C1 was later struck by a vehicle. C1 passed away as a result of injuries sustained from the accident. On November 19, 2021, the Department conducted a Case Management Visit to the facility. On that date, Department staff collected pertinent records of C1.

The investigation of C1’s death consisted of records review and interviews with relevant parties. C1 was admitted to the facility around August 16, 2016. Upon admission, C1 was identified as ambulatory. C1 was known to have a history of AWOL behavior.

Individual Program Plan (IPP) for C1 dated March 8, 2021, indicates that C1 is to have one to one supervision (line of sight). In addition, staff records show training completed in regard to C1 supervision needed.

Prior to AWOL on November 16, 2021, C1 was last observed going into the restroom. Interviews with multiple facility staff, including Staff #1 (S1) and Staff #2 (S2), as well as other pertinent individuals was conducted. Those interviewed confirmed acknowledgement that C1 required one to one supervision at all times. Facility staff were also aware of C1’s propensity to AWOL. On November 16, 2021, facility staff did not observe C1 after C1 exited the restroom. S2 also acknowledged that facility staff did not maintain a line of sight of C1, and as a result, C1 was able to leave the facility without supervision.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573
VISIT DATE: 10/11/2023
NARRATIVE
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Based upon the evidence gathered during the investigation, it was found that facility staff failed to provide C1 with required supervision. As a result, C1 left the facility and was struck by a vehicle and passed away as a result of injuries. The following deficiency is issued in accordance with Title 22 Regulations.

In addition, an Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code 1548 (e )(1)

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
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Document Has Been Signed on 10/11/2023 10:01 AM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 10/11/2023 at 09:17 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: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
80065(a)

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80065 Personnel Requirements(a)
Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

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Administrator shall read cited section and submit proof to the Regional Office (RO) that they have read the cited section by POC due date 10/12/2023. Administrator shall train all staff on the cited section at a later date.
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This requirement was not met as evidenced by:
On November 16, 2021, Licensee failed to insure that C1 was provided with one to one supervision as required to meet their needs. C1 left the facility unsupervised and was subsequently hit by a vehicle and passed away as a result of injuries. This violation of regulation posed an immediate risk to C1.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
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