366424644-1-15-2026-56-AS-MECA-DQCSQE-20260115130437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424644
Report Date: 01/15/2026
Date Signed: 01/15/2026 01:04:58 PM

Document Has Been Signed on 01/15/2026 01:04 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 VICTORVILLE		FACILITY NUMBER:	366424644
ADMINISTRATOR/ DIRECTOR:	LIMETRIUS JONES		FACILITY TYPE:	775
ADDRESS:	13901 AMARGOSA RD STE 103		TELEPHONE:	(760) 962-9339
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY: 85		CENSUS: 49	DATE:	01/15/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:32 AM
MET WITH:	Lala Jones- Program Manager		TIME VISIT/ INSPECTION COMPLETED:	01:23 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced required Annual Inspection. LPA was greeted and granted entrance at the reception area by staff, Julie Green. LPA identified herself and discussed the purpose of the visit to Program Manager, Limetrius (Lala) Jones. The facility is currently licensed as an Adult Day Program and has 49 clients present. LPA conducted 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 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 115 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. There is no medication on site. LPA observed sufficient staff present for the number of clients in care. LPA observed fire extinguishers, smoke alarms, carbon monoxide alarms, and first aid kit in the facility. LPA reviewed the program's emergency disaster plan, infection control plan, liability insurance and emergency drills.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 01/15/2026

NARRATIVE

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LPA reviewed nine (9) client files for admission agreements, updated physician reports, and needs and services plans. LPA observed 3 client files with IPP older than a year. Deficiency issued. LPA observed that one client did not have a physician's report in their file. Deficiency issued. LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Two deficiencies were cited today. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D and appeal rights were discussed and provided Program Manager, Lala Jones.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/15/2026 01:04 PM - It Cannot Be Edited

Created By: Michelle Echeverria On 01/15/2026 at 12:41 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 ADULT BEHAVIORAL CENTER VICTORVILLE	FACILITY NUMBER: 366424644
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82068.2(d)(1)

Needs and Services Plan

(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the program manager did not comply with the section cited above by not having updated IPPs for 3 clients which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2026
	Plan of Correction
1 2 3 4	Program manager stated that she will request the updated IPPs for all 3 clients and send proof to LPA via email by POC due date.

Type B

Section Cited

CCR

82069(a)

Client Medical Assessments

(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the program manager did not comply with the section cited above by not having a physician's report for one client which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2026
	Plan of Correction
1 2 3 4	Program manager stated that she will obtain the missing client physician report and submit proof to LPA via email by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:

	Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC809 (FAS) - (06/04)

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