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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423574
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:25:50 PM

Document Has Been Signed on 10/15/2024 02:25 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 APACHEFACILITY NUMBER:
366423574
ADMINISTRATOR/
DIRECTOR:
REBA JORDANFACILITY TYPE:
735
ADDRESS:16055 APACHE RDTELEPHONE:
(760) 240-0808
CITY:APPLY VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Reba JordanTIME VISIT/
INSPECTION COMPLETED:
02:31 PM
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Licensing Program Analysts (LPAs) Magda Malcore and Becky Mann made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Reba Jordan, Administrator, and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (4). The facility is a certified Inland Regional Center (IRC) vendor. LPAs conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. Outdoor activity space is shaded and enclosed with a latching gate. The facility is equipped with smoke/operating carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, and telephone service. The facility has a sufficient supply of bed linen, towels, and hygiene products for clients in care. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, and sufficient lighting. Client bathrooms were operating in safe conditions. The hot water in client bathrooms tested at 108 and 109 degrees F. Sharps, disinfectants and cleaning supplies were store in a locked cabinet. The facility has posted: Community Care Licensing complaint contact information, emergency telephone numbers, client personal rights, evacuation sketch, activities, weekly menu and facility license.

Food Service: The facility’s dining and kitchen areas were maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care.

Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked cabinet.

Personnel/Client Records: Four (4) staff records were reviewed for health screenings, criminal record clearances, and first aid/CPR training certifications. Four (4) client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs.

Technical Advisories were issued and no deficiencies were cited during today’s visit. An exit interview was conducted, where this report was discussed and a copy was provided to the Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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