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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202394
Report Date: 11/28/2023
Date Signed: 11/29/2023 08:43:33 AM

Document Has Been Signed on 11/29/2023 08:43 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:STACEY MCGLAUGLINFACILITY TYPE:
735
ADDRESS:1268 CONSTITUTION STTELEPHONE:
(559) 685-9006
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 5CENSUS: 5DATE:
11/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Stacey Mclauglin, Administrator
Christopher Trevilla, Director of Compliance		TIME COMPLETED:
04:01 PM
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On 11/28/23, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver the report from the 11/21/23 visit. LPA was greeted by staff, stated the purpose of the visit and was allowed entry into the facility.

LPA has returned to the facility to complete and deliver the report and deficiencies from LPA's visit on 11/21/23. Due to technical difficulties LPA was unable to deliver report at the time of visit.

Administrator was called by staff and arrived to the facility shortly. LPA toured the facility again with Administrator. Director of Compliance arrived to the facility and also conducted a tour with LPA to discuss plans of correction and repairs throughout the facility.

LPA reviewed the report from the 11/21/23 visit with Administrator. Deficiencies were issued on the 11/21/23 report. Plans of corrections were discussed and developed with Administrator with POC dates of 12/01/23 and 12/08/23.

During the visit, LPA obtained Individual Performance Plans (IPP's) for all residents in care.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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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