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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206290
Report Date: 05/21/2022
Date Signed: 05/21/2022 02:15:39 PM

Document Has Been Signed on 05/21/2022 02:15 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:
01:23 PM
MET WITH:Administrator Emily CarpenterTIME COMPLETED:
02:15 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 conducted a Case Management to follow up on an incident report on 4/07/22 of missing P & I funds. LPA was met by Staff Desiree Cortez and Administrator Emily Carpenter discussed the purpose of the visit.

LPA interviewed staff. LPA reviewed P & I records. Facility filed a police report with the Visalia Police Department 22-028919. Facility conducted an internal investigation and will provide copies of the staff's file.

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

An exit interview was conducted with the Administrator, a copy of this report, Plans of Corrections and appeal rights were provided.
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)
Page: 1 of 2
Document Has Been Signed on 05/21/2022 02:15 PM - It Cannot Be Edited


Created By: Shawna Doucette On 05/21/2022 at 01:53 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 B
05/23/2022
Section Cited
CCR
80026(j)

1
2
3
4
5
6
7

80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location. This requirement was not met evidenced by:
1
2
3
4
5
6
7

Plan of Correction POC Licensee agrees to immediately return all funds to clients in care and submit wriitten proof of amount missing and amount returned by POC due date. Licensee will submit written statement on how this regulation will be met.
8
9
10
11
12
13
14
 The Licensee did not secure or have record of all clients P & I funds, where all client funds and records were all missing. This poses a potential health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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)
Page: 2 of 2