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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424489
Report Date: 03/04/2024
Date Signed: 03/04/2024 02:10:04 PM

Document Has Been Signed on 03/04/2024 02:10 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:LAWANNA JONESFACILITY TYPE:
735
ADDRESS:13263 PERIGNON PLTELEPHONE:
(909) 217-9635
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
03/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Melinda Corbin-StaffTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20240227092232. LPA met with staff, Melinda Corbin.


During today's visit, LPA conducted a health and safety check and reviewed facility records. LPA found the following issues:
  • Insufficient supply of 2 days of perishables and 7 days of nonperishables.
  • Broken refrigerator door.
  • A client admitted to the facility without the approval of the licensing agency for a protective device to be used.
These pose an immediate and potential health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report, LIC809D, and appeal rights were discussed with and provided to the administrator, Lawanna Jones who later arrived.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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 3
Document Has Been Signed on 03/04/2024 02:10 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 03/04/2024 at 01:00 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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2024
Section Cited
CCR
85076(d)(1)

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85076(d)(1) Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
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Facility replenished the 7 days of nonperishables and 2 days of perishables during LPA's visit. POC cleared.
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Based on observation, the administrator did not comply with the section cited above in providing sufficient supply of perishables and nonperishables food and snacks which poses an immediate health, safety or personal rights risk to persons in care.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/04/2024 02:10 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 03/04/2024 at 01:05 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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2024
Section Cited
CCR
80087(a)

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80087(a) Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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Administrator stated that she will submit a request for the refrigerator to be fixed and if not able to get fixed then a new refrigerator will be purchased and installed. Administrator will submit proof to LPA via email by POC due date.
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Based on observation, the administrator did not comply with the section cited above in maintaining the refrigerator safe and in good repair which poses a potential health, safety or personal rights risk to persons in care.
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Type B
03/18/2024
Section Cited
CCR80072(a)(8)(F)

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80072(a)(8)(F) Personal Rights
(a) Except for children’s residential facilities, each client... to, the following: (8) Not to be placed in any restraining device. Postural supports.... following conditions: (F) Protective... as specified below. This requirement is not met as evidenced by:
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Administrator stated that she will review the regulation cited and submit a statement of understanding to LPA via email by POC due date.
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Based on observation and record review, the administrator did not comply with the section cited above by allowing a client's admission to the facility with a protective device without obtaining the licensing agency approval.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024


LIC809 (FAS) - (06/04)
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