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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206666
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:14:25 PM

Document Has Been Signed on 11/17/2023 03:14 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 VASSARFACILITY NUMBER:
547206666
ADMINISTRATOR:ENNIS,KRISTENFACILITY TYPE:
735
ADDRESS:4224 E VASSAR AVETELEPHONE:
(559) 622-8955
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 4DATE:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Direct Support Professional (DSP) Jessie Guerrero & Acting Administrator Stacey MclaughlinTIME COMPLETED:
03:15 PM
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An unannounced Annual/year visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Direct Support Professional (DSP) Jessie Guerrero. Acting Administrator (AA) Stacey Mclaughlin was not available @ time of visit however LPA was able to speak with AA over phone stating purpose of visit & AA authorizing DSP to sign for receipt of this report. AA was able to join LPA a during visit.

Physical plant toured. Dining & living rooms have required seating & lighting. Client bedrooms toured. Bedrooms havefurnishings & lighting. Bathroom used by client(s) toured. Bathroom appeared to be clean with no unpleasant odors. Hot water measured @ 116 degrees F. Interior & exterior passageways observed to be clear with no obstructions. Locked storage observed for cleaning products making them inaccessible to clients.

Facility appeared to be clean with no unpleasant odors. Interior & exterior passageways observed to be clear with no obstructions. Medications locked.
Client present @ time of visit appeared to be well groomed.
Fire extinguisher date: 1/10/2023.

Exit interview held with AA. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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