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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426473
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:57:42 PM

Document Has Been Signed on 10/29/2024 03:57 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:KENNETH ADULT RESIDENTIAL IVFACILITY NUMBER:
366426473
ADMINISTRATOR/
DIRECTOR:		CHAVEZ, JAMES EFACILITY TYPE:
735
ADDRESS:4068 MIRA MESA AVE.TELEPHONE:
(909) 342-9551
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Sylvia Chavez and James Chavez, LicenseesTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On this date, Licensees Sylvia and James Chavez met with Regional Manager (RM) Leslie Mendiveles, Licensing Program Manager (LPM) Karen Clemons and Licensing Program Analyst (LPA) Javier Prieto. Also in attendance was Genii Greco, Inland Regional Center (IRC) Quality Assurance Program Manager and Dalila Balderas, IRC Program Administrator Quality Assurance. The purpose of the meeting was to discuss recent bankruptcy filing and facility operations.

Licensees provide all with current status and next steps in regards to the bankruptcy filing. In addition, licensee reported no changes in facility operations. At this time, it appears that no immediate issues are indicated. Licensee agrees to be incompliance with Title 22 Regulations and report to the Regional Office as required. In addition, Licensee agrees to the following:

1. Insure follow-up with Plan of corrections due following deficiency issued on October 25, 2024.

2. Inform the Regional Office if there are any changes in the facility operations, to include changes on control of property.

3. Submit current facility staff (LIC 500) to Regional Office by November 1, 2024

4. Submit current resident roster to Regional Office by November 1, 2024.

In addition, licensees were informed that the Regional Office will be conducting increased visits to facility to insure compliance and health and safety of clients in care.

An exit interview was conducted with Licensees. Copy of this report was provided to Mr and Mrs Chavez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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