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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424489
Report Date: 01/19/2024
Date Signed: 01/19/2024 11:52:32 AM

Document Has Been Signed on 01/19/2024 11:52 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:LAWANNA JONESFACILITY TYPE:
735
ADDRESS:13263 PERIGNON PLTELEPHONE:
(909) 217-9635
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
01/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:LaWanna Jones, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility to conduct a Health and Safety case management visit. This case management visit is in response to an adult death of resident #1 (R1). LPA Prieto met with Administrator Jordan and explained the purpose of the visit.

During today’s visit, LPA Prieto conducted a facility tour and an interview. LPA Prieto advises MS Jordan that this may require an additional visit to obtain documentation.

No deficiencies were cited during this visit. An exit interview was conducted with MS Jordan and a copy of this report was left with facility.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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