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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800193
Report Date: 11/25/2025
Date Signed: 11/25/2025 02:41:13 PM

Document Has Been Signed on 11/25/2025 02:41 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:
11/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Dameon Lester-Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:58 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michelle Echeverria and Becky Mann arrived at the facility unannounced to conduct a required Annual visit. LPAs were greeted by assistant administrator Dameon Lester and granted entrance. LPAs introduced self and stated the purpose of the visit. LPAs observed that all clients were not home. LPAs began the tour of the facility with Dameon.

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. LPAs completed a walk through of facility, review of records, medication and P&I audit.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPAs inspected clients bedrooms; they are equipped with required furniture per regulations. LPAs inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPAs observed that the facility did not have mattress protectors for 3 beds and sufficient bedding linen and towels for all clients. Deficiency issued. LPAs tested the water temperature which tested at 110 degrees Fahrenheit. LPAs observed that the facility did not have toothpaste,deodorants, and sanitary pads available. Deficiency issued. The facility is equipped with operating fire extinguishers, smoke alarms and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for clients/staff files, first aid kit and medication. The facility has a working telephone line. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/25/2025
NARRATIVE
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. LPAs observed the front bedroom and master bedroom window screens not in good repair. Deficiency issued. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPAs reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPAs observed that the facility did not have 2 TB screenings for 2 staff and 1 health screening missing. Deficiency issued. LPAs observed that the facility did not have active CPI training for 2 staff. Deficiency issued. Medication was audited and matched to MARS. P&I was audited and matched with the ledger. LPAs reviewed facility's file for emergency drills, infection control plan, emergency disaster plan, liability insurance and surety bond. LPAs observed that the facility did not have a copy of an infection control plan. Deficiency issued. LPAs observed that the facility had expired emergency kits and incomplete first aid kit. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and appeal rights were discussed and copies were provided to assistant administrator, Dameon Lester.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/25/2025 02:41 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/25/2025 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)(D)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.  (1) The Infection Control Plan shall include all of the following:  (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the assistant administrator did not comply with the section cited above by not having an infection control plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2025
Plan of Correction
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Assistant Administrator stated that he will complete and send proof of infection control plan LIC9282 to LPA via email by POC due date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the assistant administrator did not comply with the section cited above by having the master bedroom and front bedroom window screens in bad condition which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
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Assistant Admininstrator stated that he will replace the master bedroom and front bedroom window screens by POC due date and send proof to LPA via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/25/2025 02:41 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/25/2025 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above by not having the 3 mattress protectors and sufficient bedding linens and towels for all clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
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Assistant administrator stated that he will purchase the 3 mattress protectors and sufficient bedding linens and towels and send proof of pictures and receipts to LPA via email by POC due date.
Type B
Section Cited
CCR
85088(c)(5)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the assistant administrator did not comply with the section cited above by not having sufficient toothpaste,deodorants, and sanitary pads available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
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Assistant administrator stated that he will purchase toothpaste,deodorants, and sanitary pads and send proof of pictures and receipts to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/25/2025 02:41 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/25/2025 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the assistant administrator did not comply with the section cited above by not having 2 TB screenings for 2 staff and 1 health screening for 1 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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Assistant administrator stated that he will have the 2 TB screenings for 2 staff and 1 health screening for 1 staff completed and send proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the assistant administrator did not comply with the section cited above by not having active CPI training for 2 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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Assistant Administrator stated that he will have the 2 staff submit an active CPI training proof to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/25/2025 02:41 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/25/2025 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)(2)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the assistant administrator did not comply with the section cited above by having expired emergency kits and a missing first aid kit with manual which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
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2
3
4
Assistant administrator stated that he will purchase and send proof to LPA via email by POC due date of the emergency kits and first aid kit with manual.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
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