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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423574
Report Date: 07/14/2022
Date Signed: 07/14/2022 12:29:35 PM

Document Has Been Signed on 07/14/2022 12:29 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 APACHEFACILITY NUMBER:
366423574
ADMINISTRATOR:REBA JORDANFACILITY TYPE:
735
ADDRESS:16055 APACHE RDTELEPHONE:
(760) 240-0808
CITY:APPLY VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
07/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Reba Jordan, AdministratorTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPA’s) Rayshaun Nickolas and Amy Goldenberg made an unannounced visit to the facility to conduct a Health and Safety case management visit. This case management visit is in response to a special incident report (SIR) that was received by this agency from the facility on July 1, 2022. LPAs met with Administrator Reba Jordan and explained the purpose of the visit.

The SIR documents that on June 16, 2022, Client (C1) slapped staff (S1) and then S1 slapped C1 back. The SIR further documents that the facility management was not made aware of the incident until June 28, 2022, and management gathered written statements from five (5) members of staff about the incident.

Inquiry into this incident included conducting a tour of the facility to assess for any Health and Safety concerns. LPAs reviewed the statements provided by staff regarding the incident, interviewed the administrator, staff, and district manager, reviewed C1’s Individual Program Plan (IPP). LPAs obtained a copy of the IPP for C1.

There are no health and safety concerns observed during this visit. Additional information will be required prior to closure inquiry into this incident.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Administrator.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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