<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424116
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:24:57 PM

Document Has Been Signed on 11/29/2022 02:24 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 IVANPAHFACILITY NUMBER:
366424116
ADMINISTRATOR:CARSON, STEPHANIEFACILITY TYPE:
735
ADDRESS:14180 IVANPAH RDTELEPHONE:
(760) 946-3096
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 4DATE:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Star Pillman, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/29/2022 at 12:13 p.m., Licensing Program Analyst (LPA) Rayshaun Nickolas 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 November 28, 2022. LPA met with Administrator Star Pillman and explained the purpose of the visit.

Inquiry into this incident included conducting a tour of the facility to assess for any Health and Safety concerns. LPA conducted interviews, reviewed facility files, and gathered copies of pertinent documents.There were no health and safety concerns observed during this visit. Additional information will be required before the closure of 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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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 1