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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424644
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:29:00 AM

Document Has Been Signed on 03/21/2022 11:29 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 ADULT BEHAVIORAL CENTER VICTORVILLEFACILITY NUMBER:
366424644
ADMINISTRATOR:LIMETRIUS JONESFACILITY TYPE:
775
ADDRESS:13901 AMARGOSA RD STE 103TELEPHONE:
(760) 962-1900
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 60CENSUS: 53DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chaztiney Cloud, SupervisorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst Rohit Lama made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA identified himself and discussed the purpose of the visit. Prior to entry, facility Staff #1 (S1) required LPA to get temperature checks and ensured that LPA was masked. Chaztiney Cloud, Supervisor, stated that there were no recent positive COVID test results nor were there any individuals currently with COVID symptoms.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.

During the inspection, LPA Lama interviewed the Supervisor pertaining to the facility's infection control measures and other health and safety concerns. LPA Lama observed necessary signs posted in the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. The Supervisor stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. LPA observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

CONTINUED ON LIC 809-C

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: KAISER ADULT BEHAVIORAL CENTER VICTORVILLE
FACILITY NUMBER: 366424644
VISIT DATE: 03/21/2022
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Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was provided to Angela Sattlesbreedlove at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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