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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800089
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:20:35 PM

Document Has Been Signed on 11/30/2023 12:20 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
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: 4DATE:
11/30/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jazzmin Pruitt- AdministratorTIME COMPLETED:
12:30 PM
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On 11/30/23, Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to the facility for the purpose of change of ambulatory status. LPA was greeted and granted entrance by the Administrator, Jazzmin Pruitt.

Per the LIC200, the ambulatory capacity decreased from four (4) ambulatory to three (3) ambulatory and increased from zero (0) nonambulatory to one (1) nonambulatory on 04/28/2023. The fire clearance request was approved on 05/16/2023 for three (3) ambulatory clients and one (1) nonambulatory client.

There is a facility sketch on file with designation of ambulatory status for each room. The administrator was advised that the noted designated capacity/ambulatory status for each room is to remain in compliance.

LPA observed that the client bedrooms were appropriately furnished and had functional lighting. The physical plant is ready for a change of ambulatory status. LPA will update the facility's file and issue a new license stating change in capacity/ambulatory status.

An exit interview was conducted where this report LIC809 was discussed and provided to the Administrator,

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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