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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424644
Report Date: 09/25/2023
Date Signed: 09/25/2023 11:41:55 AM

Document Has Been Signed on 09/25/2023 11:41 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: 63DATE:
09/25/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Carlos Diaz, Employment & Educational ServicesTIME COMPLETED:
11:46 AM
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced collateral visit to conduct an interview pertinent to a complaint investigation unassociated with this facility. LPA Nickolas met with Carlos Diaz, Employment & Educational Services Supervisor and explained the purpose of the visit.

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

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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