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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800193
Report Date: 01/10/2024
Date Signed: 01/10/2024 12:43:56 PM

Document Has Been Signed on 01/10/2024 12:43 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: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: 3DATE:
01/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Ashley Taylor- LicenseeTIME COMPLETED:
12:52 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced case management visit to follow up on an incident report sent to licensing on 12/30/23. LPA introduced self and stated the purpose of the visit to Licensee, Ashley Taylor.

During today's visit, LPA performed a health and safety check, review records and interviewed Ashley to discuss the incident and surrounding events. Interview revealed that staff performed CPI on the client as the last resort because the client's behavior couldn't be deescalated. The client was moved by IRC and placed on an emergency placement to a different facility on 12/31/23.

No deficiencies were observed during this visit. An exit interview was conducted where this report was discussed and then provided to Ashley Taylor, Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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