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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423573
Report Date: 01/03/2025
Date Signed: 01/03/2025 01:04:08 PM

Document Has Been Signed on 01/03/2025 01:04 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL SERRANOFACILITY NUMBER:
366423573
ADMINISTRATOR/
DIRECTOR:		REBA JORDANFACILITY TYPE:
735
ADDRESS:16146 SERRANO AVETELEPHONE:
(760) 242-5759
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
01/03/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Reba JordanTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted a case management visit based on an incident report submitted to the regional office on 12/23/24. LPA met with Administrator Reba Jordan and informed the purpose of the visit.

Interviews with facility staff and clients reveals, on 12/22/24, staff #1(S1) hit client #1 (C1) in the face during an altercation at the facility. C1's interview reveals that they were hit by one staff which was S1. C1 was taken to the hospital on 12/22/24 for treatment to C1's left orbit. S1 was placed on unpaid leave on 12/22/24 and then terminated on 12/26/24.

A citation is being issued in accordance with Title 22, division 6, of the California Code of regulations.

A exit interview was conducted where this report and correction plans were discussed. Copies of reports (LIC809 and LIC809-D) were provided to the Administrator with Appeal rights at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 01/03/2025 01:04 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/03/2025 at 12:04 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: KAISER SPECIALIZED RESIDENTIAL SERRANO
FACILITY NUMBER: 366423573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2025
Section Cited
CCR
80072(a)(3)

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80072(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, This requirement is not met as evidenced by:
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S1's employment was terminated on 12/26/24. The Licensee/Administrator has agreed to conduct in service training which includes client personal rights and submit proof of training by POC due date.
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The licensee did not comply with the section cited above by Staff #1 hitting a client in care which poses an immediate health, safety, and personal rights risk to persons 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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