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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800189
Report Date: 06/27/2023
Date Signed: 06/27/2023 01:13:10 PM

Document Has Been Signed on 06/27/2023 01:13 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: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:
06/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Jesus Salazar, Program Coordinator & Kelly Larsen, Program DirectorTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Valley Star Crisis Residential Center, unannounced to conduct a Case Management Visit for health and safety. This case management visit is in response to a Special Incident Report, (SIR) submitted to the Community Care Licensing Office on 6/26/23. LPA was greeted by Security at the front door. LPA introduced self and stated purpose of the visit. Security notified Management of LPA's arrival, while LPA was asked to sign in. LPA met with Jesus Salazar, Facility Manager and Director.

LPA met with staff in a private room to discuss the incident and surrounding events. LPA was provided with documentation of the facility investigation. Documents included interview statements of staff and residents. As well as face sheets. Due to client/attorney privilege(s), LPA was not permitted to make/take copies of statements. LPA reviewed documentation and made notes of each interview/statements of both staff and residents.

No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to Facility Representatives/
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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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