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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 10:48:42 AM

Document Has Been Signed on 10/19/2022 10:48 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Patricia Woods, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA's) Rayshaun Nickolas and Amber Coleman made a case management visit after conducting an unrelated visit at the facility. The case management visit is in response to deficiencies cited at the facility. LPA's met with Administrator Patricia Woods.

On 10/19/2022 at 9:23 a.m., LPA's observed the screen from the office window on the ground near the front door. At 9:28 a.m., Per staff #1 (S1) interview, LPA discovered the office door was broken, prohibiting the facility staff from entering the office. Per S1, the office door broke as the staff was escaping from an aggressive client. S1 also indicated that they existed the office from the office window when the office door broke.

Based on observations and interviews made during today’s inspection, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations (CCR). An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were given 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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Document Has Been Signed on 10/19/2022 10:48 AM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 10/19/2022 at 10:23 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
, CA 92507

FACILITY NAME: 11848 TRAILWOOD STREET
FACILITY NUMBER: 361800089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
80087(a)

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80087 (a) Buildings 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:
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Licensee shall ensure that the office door is repaired. The administrator states the repair man will be arriving by 1:00 p.m. on October 19, 2022. However, the administrator requests to have 30-days to repair the lock just in case issues arise. Proof of correction shall be submitted to the RO by 11/18/2022.
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Based on observation & interview, the licensee did not ensure that the office door was in good repair, which poses a potential health, safety, and personal rights risks to persons in care
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Type B
10/19/2022
Section Cited
CCR80087(a)

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80087 (a) Buildings 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
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Licensee shall ensure that the screen on the office window is repaired. Proof of correction shall be submitted to the Ro by 10/19/2022.
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Based on observation & interview, the licensee did not ensure that the screen for the office window was in good repair, which poses a potential health, safety, and personal rights risks to persons in care.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


LIC809 (FAS) - (06/04)
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