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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800193
Report Date: 01/03/2023
Date Signed: 01/03/2023 11:05:14 AM

Document Has Been Signed on 01/03/2023 11:05 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRUST & GRACE ADULT CARE HOMEFACILITY NUMBER:
361800193
ADMINISTRATOR:MARTIN, CHERRYFACILITY TYPE:
735
ADDRESS:12295 ANDREA DRIVETELEPHONE:
(760) 488-1602
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: DATE:
01/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Daemon Lester, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Trust & Grace Adult Care Home unannounced to conduct the annual inspection with a focus on infection control. LPA introduced sefl and stated purpose of the visit. LPA was greeted by Administrator, Daemon Lester and invited inside the facility. Upon entry, LPA was asked to have temperature taken and to sign in. LPA observed COVID station equipped with PPE, hand sanitizer and sign in sheets. Administrator shared the current census is 4, although 3 are at program at time of visit. 1 resident was present in his room during visit.

During the inspection, LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. LPA reviewed resident records and interviewed Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2023
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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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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193
VISIT DATE: 01/03/2023
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LPA observed the resident's medications, sharp objects and medication records secure in a closet in the hallway. A secure file cabinet kept in living area #1 holds all resident charts and employee personnel files. Adequate food supply observed in the kitchen pantry and refrigerator. Emergency food supply kept in kitchen cabinet. Fire and carbon monoxide alarms tested and found operational. Fire extinguisher last inspected 11/21/22. Backyard held no bodies of water, patio furniture kept elsewhere due to the current weather conditions.

Inspection Tool was utilized, Mitigation Plan reviewed, Facility was further inspected, and no deficiencies were noted. A copy of this report was provided to Administrator Daemon Lester.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC809 (FAS) - (06/04)
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