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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800193
Report Date: 11/19/2024
Date Signed: 11/19/2024 07:53:22 PM

Document Has Been Signed on 11/19/2024 07:53 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/
DIRECTOR:		MARTIN, CHERRYFACILITY TYPE:
735
ADDRESS:12295 ANDREA DRIVETELEPHONE:
(760) 488-1602
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:40 PM
MET WITH:Dameon Lester-Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
08:09 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required annual inspection visit. LPA introduced self and stated the purpose of the visit to DSP, Magnolia Carrasco. LPA was informed that 3 clients were home and 1 client on an outing with their 1:1 staff. LPA toured the facility with Magnolia Carrasco.

The facility has 4 bedrooms, 2 bathrooms, a kitchen, dining area, entry/office room, family room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility, review of records, and P&I audit. Due to timing restriction, LPA was not able to complete the annual inspection and will continue on a different day. No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 was discussed and a copy was provided to Assistant Administrator, Dameon Lester who later arrived after the tour inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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