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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800193
Report Date: 01/23/2024
Date Signed: 01/23/2024 03:50:27 PM

Document Has Been Signed on 01/23/2024 03:50 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:
01/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Dameon Lester- DSPTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced case management visit to conduct a health and safety check. LPA introduced self and stated the purpose of the visit to DSP, Dameon Lester.

During today's visit, LPA observed a hole on the closet door where medication is stored and another hole on the wall across the closet door. DSP stated that the facility was waiting on the landlord's response to get it fixed.

Deficiency issued during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were discussed and then provided to DSP, Dameon Lester.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/23/2024 03:50 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 01/23/2024 at 03:27 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: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
80087(a)

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80087(a) Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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DSP covered the holes on the wall with tape and cardboard. DSP stated that he will repair the holes on the wall and submit pictures as proof to LPA via email by POC due date. Licensee stated that she will review the regulation cited and submit a statement of understanding to LPA via email by POC due date.
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Based on observation, the licensee did not comply with the section cited above in maintaining the facility safe and in good repair which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024


LIC809 (FAS) - (06/04)
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