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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424644
Report Date: 11/01/2023
Date Signed: 11/01/2023 11:11:40 AM

Document Has Been Signed on 11/01/2023 11:11 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: DATE:
11/01/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Lala Jones- Program ManagerTIME COMPLETED:
11:18 AM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility 11/01/2023 at 10:10 AM, unannounced for a collateral visit to interview a client regarding an SIR received at CCL for the facility where the client resides. During this visit LPA was met by Program Manager, Lala Jones.

LPA interviewed client through phone number provided due to client was out in the community doing work.

An exit interview was conducted and a copy of this report (LIC809) was discussed and provided to Program Manager, Lala Jones.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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