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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206290
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:13:29 AM

Document Has Been Signed on 09/19/2024 11:13 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 TAYLORFACILITY NUMBER:
547206290
ADMINISTRATOR/
DIRECTOR:		CARPENTER,EMILYFACILITY TYPE:
735
ADDRESS:2816 W TAYLOR AVETELEPHONE:
(559) 636-2590
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 3DATE:
09/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:13 AM
MET WITH:Administrator, Emily CarpenterTIME VISIT/
INSPECTION COMPLETED:
11:27 AM
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On 09/19/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management inspection. LPA contacted Administrator, Emily Carpenter, via telephone, introduced self, and stated the purpose of the visit. Administrator arrived at the facility a short time later, and granted LPA entry to the facility.

There are no clients present during today's inspection.

The purpose of this visit is to follow up on an incident that was self-reported to the Fresno CCL office on 03/28/24. It was reported that on 03/17/2024, S2 verbally threatened a client in care and on 03/26/2024, S2 "aggressively pulled" the arm of a client in care.

LPA is requesting for the following documents to be submitted to the Fresno CCL office by 09/20/2024: staff schedule for March 2024, staff contact information and current client roster. LPA is requesting the following for S1 and S2: Job application, job description, medical assessment, criminal record clearance, any disciplinary actions or write ups, and any documentation relevant to the incident. LPA is also requesting the following documents for C1 and C2: emergency/ID sheet, admission agreement, physician's report, needs/services or care plan, IPP, and functional capabilities assessment.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Emily Carpenter, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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