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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800089
Report Date: 10/19/2022
Date Signed: 10/19/2022 10:47:14 AM

Document Has Been Signed on 10/19/2022 10:47 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:11848 TRAILWOOD STREETFACILITY NUMBER:
361800089
ADMINISTRATOR:PATRICIA WOODSFACILITY TYPE:
735
ADDRESS:11848 TRAILWOOD STREETTELEPHONE:
(323) 395-8594
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 2DATE:
10/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Patricia Woods, Administrator TIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA’s) Rayshaun Nickolas and Amber Coleman made an unannounced visit to the facility to conduct a Health and Safety case management visit. This case management visit is in response to a special incident report (SIR) that was received by this agency from the facility on October 14, 2022. LPA's arrived and met with caregiver Sanaa Nikelson and explained the purpose of the visit. Administrator Patricia Woods would later arrive at the facility,

The SIR documents that on 10/11/2022, Resident # 1 (R1) reported being sexually assaulted by their papa.

Inquiry into this incident included conducting a tour of the facility to assess for any Health and Safety concerns. LPA's reviewed the statements provided by staff regarding the incident, interviewed the administrator, staff, and clients in care. There are no health and safety concerns observed during this visit. Additional information will be required before the closure of this incident.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Administrator.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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