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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424489
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:09:37 AM

Document Has Been Signed on 08/22/2023 11:09 AM - 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 PERIGNONFACILITY NUMBER:
366424489
ADMINISTRATOR:JOYNER, NICOLEFACILITY TYPE:
735
ADDRESS:13263 PERIGNON PLTELEPHONE:
(909) 217-9635
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 3DATE:
08/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:LaWanna Jones, Administrator TIME COMPLETED:
11:15 AM
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On August 22, 2023, at 10:35 a.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 this agency received from the facility on August 21, 2023. LPA Nickolas met with caregiver Edwin Agliam and explained the purpose of the visit. LPA Nickolas requested that the administrator be called. Administrator LaWanna Jones arrived approximately 10 minutes later.

During today’s visit, LPA Nickolas conducted a facility tour and a interview. LPA Nickolas advises Jones that this incident requires further investigation, and possible follow-up telephone calls and visits are necessary before the closure of this incident.

No deficiencies were cited during this visit. An exit interview was conducted with Jones, and a copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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