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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800189
Report Date: 11/15/2022
Date Signed: 11/15/2022 10:25:18 AM

Document Has Been Signed on 11/15/2022 10:25 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:VALLEY STAR CRISIS RES. TREATMENT-HIGH DESERTFACILITY NUMBER:
361800189
ADMINISTRATOR:SYLVIA RODRIGUEZFACILITY TYPE:
772
ADDRESS:16552 SUNHILL DRIVETELEPHONE:
(760) 780-4400
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 16CENSUS: 15DATE:
11/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Kelly Larsen, Program Manager
Jesus Salazar, Quality Assurance		TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting a case management visit for the purpose of a health and safety check. LPA met with Program Manager, Kelly Larsen and Quality Assurance, Jesus Salazar. LPA explained the nature of the visit in relation to an incident reported received 11/10/2022 self reporting personal rights violation of R1 by employee S1.

During this visit LPA conducted a tour of the facility and verified that the facility health and safety mandates are being met. LPA observed that residents bedrooms are safe and furnished comfortably, all medications, chemicals, and dangerous equipment is locked inaccessible to residents in care. PPE, emergency food supply, and daily available food is adequately stocked. LPA observed residents in care engaged in group activities and do not appear to be in any immediate danger.

LPA requested and was provided copies of employee and resident records for resident R1 and employee S1. LPA advised the facility representatives that additional inquires into this incident will be required prior to closure of review of this incident.

This report was reviewed with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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