Entity Details

Basic

Entity Type:
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

Former Entity Name:
Childserve Johnston Duplex South

Medicaid #:
0881482

CCN #:
16G129

Occupancy Type:
Beds

Max Occupancy:
4

Status:
Active

Close Date:

Accredited:
No Record Found

Accredited/Deemed:
No Record Found

License & Survey

License #:
770972

Initial License Date:

Current License Date:
05/02/2024

Renewal Cycle:
365

Entity Type Renewal Cycle(months):
12

Expiration Date:
05/02/2025

Months Since Last Survey:
8

Entity Type Survey Cycle(months):
12

Special Focus Facility:
No

Loss of NA Training Effective:

Loss of NA Training Expires:

Contact

Address:
5897 NW 54th Ct

City:
Johnston

State:
Iowa

Zip:
50131

Phone:
(515) 727-8726

Fax:
(515) 727-8727

URL:

Administrator/License #:
Stephanie Malone /

Administrator Email:
Stephas@childserve.org

Files

Life Safety Code (LSC) Waiver:

Licensure Rule Variance: