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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 12:21:32 PM

Document Has Been Signed on 11/30/2023 12:21 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 - DeficienciesANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jazzmin Pruitt- AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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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 where deficiencies were found during observations. LPA was greeted and granted entrance by the Administrator, Jazzmin Pruitt.

During the tour of the facility, LPA observed the following deficiencies:

The facility does not have a supply of minimum 7 days non-perishable foods and 2 days of perishable foods. Fireplace is accessible to clients in care.

Based on observations 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: 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)
Page: 1 of 2
Document Has Been Signed on 11/30/2023 12:21 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/30/2023 at 11:59 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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
85076(d)(1)

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85076(d)(1) Food Service
(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable..maintained on the premises. This requirement is not met as evidenced by:
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Administrator stated that groceries will be purchased tomorrow and a picture of groceries along with a copy of receipt will be sent via email to LPA by POC due date.
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Based on observations, the administrator did not comply with the section cited above by maintaining a minimum supply of perishable and nonperishable foods which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
12/07/2023
Section Cited
CCR80088(c)

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80088(c) Furniture, Fixtures, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be made inaccessible to clients to ensure protection of the clients' safety. This requirement is not met as evidenced by:
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Administrator stated that a fireplace barrier cover will be purchased and a picture of cover and copy of receipt will be sent via email to LPA by POC due date.
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Based on observations, the administrator did not comply with the section cited above by maintaining the fireplace inaccessible to clients which poses a potential health, safety or personal rights risk 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2