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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800089
Report Date: 04/25/2023
Date Signed: 04/25/2023 11:42:18 AM

Document Has Been Signed on 04/25/2023 11:42 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 1DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Jazzmin Pruitt, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the 11848 Trailwood Street Adult Residential Facility for the purposes of conducting an Annual Inspection. LPA was greeted by Facility Administrator Jazzmin Pruitt and Staff Member Joseph. LPA introduced self and stated purpose of the visit. LPA was granted entry and provided space to work. Administrator reported that 3 residents in care are attending their Day Programs; leaving 1 resident at the facility for the day.

The facility is a five (5) bedroom, two (2) bathroom home, with a kitchen/dining area, living rooms, and attached garage. The facility is an Adult Residential Facility (ARF) is vendorized by Inland Regional Center. Licensed capacity is (4). LPA was accompanied by Facility Administrator to conduct a general overall inspection, which included, a walk through of premises and file review.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility was observed to be at a comfortable temperature LPA observed resident bedrooms; which included required furniture such as: mattresses, night stands, storage space, and adequate lighting; bathrooms observed to be clean and included adequate handsoap and paper products. Appliances were operating appropriately. LPA observed adequate furniture, seating and lighting throughout the facility. The hot water temperature tested within regulation The facility is equipped with operational smoke/carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. Staff/Resident files are kept in a secure staff office. Medications are kept inside a secure closet inaccessible to clients.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: 11848 TRAILWOOD STREET
FACILITY NUMBER: 361800089
VISIT DATE: 04/25/2023
NARRATIVE
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LPA completed a walk through of the facility's backyard area. At approximately 9:40am LPA observed a wall aside the kitchen with a dented and cracked dry wall in a circle shape. The cracked dry wall was near the bottom of the wall, at the height of the wall outlet. Administrator has made plans to have the wall fixed on the following date. LPA reviewed staff and resident files and observed 2 files to have missing information. LPA observed the posted facility license. The facility is licensed for 4 ambulatory only residents. At this time, the facility has 1 resident in care with an non-ambulatory.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also sufficient for the residents in care.

Based on today’s inspection, deficiencies were observed at this time in the areas evaluated. Please refer to 809D for citations given during inspection. An exit interview was conducted. This report was discussed with Administrator and a copy was furnished. Appeal rights were discussed.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/25/2023 11:42 AM - It Cannot Be Edited


Created By: Amber Coleman On 04/25/2023 at 11:04 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: 11848 TRAILWOOD STREET
FACILITY NUMBER: 361800089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of the facility wall near the kitchen being cracked, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2023
Plan of Correction
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Administrator completed the plan of correction during the visit. Maintence arrived and fixed the cracked dry wall.
Type B
Section Cited
CCR
80069(b)(1)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of the resident files; missing documents the licensee did not comply with the section cited above in two (2) out of four (4) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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Administrator will review the regulations for resident records and submit a statement of understanding of the regulation by way of a LIC9098 form; then sumbit the completed form to the Community Care Licensing Office. Administrator will all obtain the missing information for each resident file in question. These tasks should be completed within 30 days.
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:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2023 11:42 AM - It Cannot Be Edited


Created By: Amber Coleman On 04/25/2023 at 11:28 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: 11848 TRAILWOOD STREET
FACILITY NUMBER: 361800089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
80010 Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in one (1) out of four (4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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Adminstrator will have the resident re-evaluated by the Primary Care Physician. If resident is deemed non-ambulatory, the resident will need to relocate.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


LIC809 (FAS) - (06/04)
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