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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424489
Report Date: 11/08/2024
Date Signed: 11/08/2024 02:19:48 PM

Document Has Been Signed on 11/08/2024 02:19 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 PERIGNONFACILITY NUMBER:
366424489
ADMINISTRATOR/
DIRECTOR:		LAWANNA JONESFACILITY TYPE:
735
ADDRESS:13263 PERIGNON PLTELEPHONE:
(909) 217-9635
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Ricquan JonesTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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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 Direct Support Staff II (DSP) Ricquan Jones, granted entry into the facility, 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 & carbon monoxide alarms, two (2) 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. Four (4) client bedrooms were equipped with beds, bed linen, nightstands, chairs, and lighting. Client bathrooms were operating in safe conditions. The hot water in client bathrooms tested at 107 and 105.2 degrees F. Sharps, disinfectants and cleaning supplies were stored in a locked cabinet. The facility has 24 hour/7 days a week care staff. The facility has posted: Community Care Licensing complaint contact information, emergency telephone numbers, client personal rights, evacuation sketch, 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: Staff files were not available for LPAs to review. LPA's spoke with Administrator Lawanna by telephone who stated that staff files are kept locked and current staff do not have access to them. Four (4) client records were reviewed for admission agreements, medical assessments, needs and service plans. Client P&I funds and ledgers were not available for LPAs to review. The Administrator stated that client P&I records were kept locked and current staff do not have access to them.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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Document Has Been Signed on 11/08/2024 02:19 PM - It Cannot Be Edited


Created By: Magda Malcore On 11/08/2024 at 01:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL PERIGNON
FACILITY NUMBER: 366424489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
Personnel Records (c)All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by current staff not having access to staff training, employment history, and health screenings files for licensing to review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency a statement of understanding on the regulation cite above by Plan of correction date
Type B
Section Cited
CCR
80026(h)(1)
Safeguards for Cash Resources, Personal Property, and Valuables of Resident (h)Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1)Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above by not having records of clients P&I ledgers and cash funds for licensing to review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency a statement of understanding on the regulation cite above by Plan of correction date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PERIGNON
FACILITY NUMBER: 366424489
VISIT DATE: 11/08/2024
NARRATIVE
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Based on the LPA's observations made during today’s visit, Deficiencies and technical advisories were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted were reports (LIC809/LIC809-D/LIC9102) and a plan of correction were discussed. Copies of the reports were provided with appeal rights to DSP II Jones at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 11/08/2024 02:19 PM - It Cannot Be Edited


Created By: Magda Malcore On 11/08/2024 at 01:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL PERIGNON
FACILITY NUMBER: 366424489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not having all client records for licensing to review and inspect on demard; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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The Licensee/Administrator shall submit to the licensing agency a statement of understanding on the regulation cite above by Plan of correction date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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