<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800089
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:22:19 PM

Document Has Been Signed on 06/20/2024 04:22 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/
DIRECTOR:		SHANELLREYA KNOWLESFACILITY TYPE:
735
ADDRESS:11848 TRAILWOOD STREETTELEPHONE:
(323) 395-8594
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Shanellreya Knowles-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:32 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Staff, Aveon Popoola and granted entrance. LPA introduced self and stated the purpose of the visit. LPA observed that there is currently one client in the facility and 3 in day program. LPA toured the facility with Administrator, Shanellreya Knowles who later arrived.

The facility has 4 bedrooms, 2 bathrooms, a kitchen, dining area, living room, family room, office, laundry room, garage and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 77 degrees fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in the laundry room. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. Water temperature in the bathroom tested at 116.5 degrees fahrenheit. The facility is equipped with operating fire extinguishers, smoke alarms and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for clients/staff files, first aid kit and medication. LPA observed that the telephone line was not functioning. Administrator stated that the line stopped working a month ago. Deficiency issued. There are no pools, bodies of water, firearms or ammunition. LPA observed a missing window screen on the bedroom to the left of the family room. Deficiency issued.
Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/20/2024 04:22 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/20/2024 at 01:55 PM
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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the administrator did not comply with the section cited above in providing a window screen on the bedroom to the left of the family room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
1
2
3
4
Administrator stated that she will have a window screen installed on the bedroom to the left of the family room and send a picture to LPA via email by POC due date.
Type B
Section Cited
CCR
80073(a)
Telephones
(a) All facilities shall have telephone service on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the administrator did not comply with the section cited above in providing a functioning telephone line on the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
1
2
3
4
Administrator stated that she will have the telephone line repaired and submit proof to LPA via email by POC due date.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 06/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds were counted at random and matched with the ledger. Medication was audited at random and matched with the MARS. The facility last conducted a disaster drill in May 11, 2024.

Two deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to Administrator, Shanellreya Knowles.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3