366424311-12-26-2024-56-AS-BMAN-DCBT5B-20241226132515

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424311
Report Date: 12/26/2024
Date Signed: 12/26/2024 01:25:35 PM

Document Has Been Signed on 12/26/2024 01:25 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	KAISER SPECIALIZED RESIDENTIAL MERLOT		FACILITY NUMBER:	366424311
ADMINISTRATOR/ DIRECTOR:	ANAHI MURILLO		FACILITY TYPE:	735
ADDRESS:	21295 MERLOT LN		TELEPHONE:	(760) 240-9976
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY: 4		CENSUS: 3	DATE:	12/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Dontee Weaver, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Becky Mann made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection. LPA met with Dontee Weaver, Administrator. The facility is a four (4) bedroom, three (3) bathroom home with a kitchen/dining area, living room, attach garage. The facility is an Adult Residential Facility (ARF) home vendor by Inland Regional Center. Licensed capacity is 4 current census 3. LPA was accompanied by Amber Espinoza, staff to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, beds, nightstands, storage space, and sufficient lighting. Client bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested between 116 degrees and 119 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL MERLOT	FACILITY NUMBER: 366424311
	VISIT DATE: 12/26/2024

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Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed three (3) client medications. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIC809C was discussed and provided to Dontee Weaver, Administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024

LIC809 (FAS) - (06/04)

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