<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202394
Report Date: 09/14/2021
Date Signed: 09/14/2021 11:26:17 AM

Document Has Been Signed on 09/14/2021 11:26 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL CONSTITUTIONFACILITY NUMBER:
547202394
ADMINISTRATOR:KIMBERLY GONZALESFACILITY TYPE:
735
ADDRESS:1268 CONSTITUTION STTELEPHONE:
(559) 685-9006
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 5CENSUS: 5DATE:
09/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Kimberly Gonzales, AdministratorTIME COMPLETED:
11:25 AM
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) Lady Cabrera conducted an unannounced case management visit to the facility.

The purpose of the case management visit is to respond to two incident reports that were submitted to CCL Office and was dated 08/21/2021 and 09/02/2021.

LPA met with Administrator, Kimberly Gonzales and stated the purpose of the visit. LPA interviewed Administrator regarding incidents. Incident reports were regarding self injurious behaviors of C1 and C2 breaking temper glass windows. Staff provided intervention and assisted clients with de-escalation techniques. C1 and C2 were checked for injuries and were provided with first aid. C1 had a small scratche on right forearm. C2 had a small laceration on his forehead and was medically evaluated by a nurse. Follow-up was required.

LPA reviewed resident's file.

No deficiency was observed. Exit Interview was conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1