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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206290
Report Date: 05/21/2022
Date Signed: 05/21/2022 01:21:01 PM

Document Has Been Signed on 05/21/2022 01:21 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL TAYLORFACILITY NUMBER:
547206290
ADMINISTRATOR:MICHELLE VASQUEZFACILITY TYPE:
735
ADDRESS:2816 W TAYLOR AVETELEPHONE:
(559) 636-2590
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
05/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Administrator Emily CarpenterTIME COMPLETED:
01:30 PM
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Licensing Program Analyst LPA conducted a Case Management to follow up on an incident report on 3/13/22. LPA was met by Staff Desiree Cortez and Administrator Emily Carpenter discussed the purpose of the visit.

LPA interviewed staff. LPA reviewed the physician report and IPP. Client cannot leave facility unattended. Administrator will email copies of physician report and IPP.

Deficiencies are being cited based on interviews and record review in accordance with the CCR Title 22. See LIC 809D. Civil Penalties were issued.

An exit interview was conducted with the Administrator a copy of this report and appeal rights were provided. Plan of Corrections were cleared during visit.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2022
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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Document Has Been Signed on 05/21/2022 01:21 PM - It Cannot Be Edited


Created By: Shawna Doucette On 05/21/2022 at 12:53 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL TAYLOR
FACILITY NUMBER: 547206290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2022
Section Cited
CCR
85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
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Plan of Correction POC Licensee agrees to install an alarm on the outside gate and provide a written statement on how this regulation will be met. Facility installed an alarm on the outside front gate that sounds every time the gate opens. Civil Penalties were issued.
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This requirement was not met as evidenced by LIcensee did not provide supervision for C1 as C1 left the facility and was returned by police approximately 25 minutes after C1 went missing which poses an immediate Health, Safety and personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2022


LIC809 (FAS) - (06/04)
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