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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424644
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:25:45 PM

Document Has Been Signed on 03/05/2024 12:25 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 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: 74DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Carlos Diaz- Assistant Program ManagerTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced required Annual Inspection. LPA identified herself to Assistant Program Manager, Carlos Diaz and Program Supervisor, Chaztiney Cloud who were advised of the purpose of the visit. The facility is currently licensed as an Adult Day Program and has 56 clients present. LPA was accompanied by Carlos Diaz and Chaztiney Cloud to conduct a general overall inspection, which included, but was not limited to, the following:

LPA inspected the facility inside. LPA observed all passageways are clear of obstructions. The facility is maintained at a comfortable temperature of 70, 71, 73 and 71 degrees fahrenheit. LPA inspected client activity rooms 1-9; they are equipped with required furniture and activity supplies/equipment for clients. LPA inspected client bathrooms; bathroom appliances were operating in good and sanitary conditions. LPA observed grab bars in the bathrooms. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 116.6 degrees fahrenheit. Disinfectants, toxins, sharps and cleaning supplies are locked and inaccessible to clients. There are no firearms/ammunition or bodies of water.

At Day Program, clients are responsible to bring their own lunch. Snacks were accessible to clients and stored in a healthful manner. LPA observed the kitchen area to be clean, free of odors, and in a healthful manner.

LPA observed sufficient staff present for the number of clients in care. Medication is locked and inaccessible to clients in the facility. LPA observed fire extinguishers, smoke alarms, carbon monoxide alarms, and first aid kit in the facility. The last disaster drill was conducted on 2/13/24.

LPA reviewed four (4) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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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 ADULT BEHAVIORAL CENTER VICTORVILLE
FACILITY NUMBER: 366424644
VISIT DATE: 03/05/2024
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Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809 and LIC809C were discussed and provided to Carlos Diaz and Chaztiney Cloud.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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