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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800193
Report Date: 02/25/2025
Date Signed: 02/25/2025 11:51:55 AM

Document Has Been Signed on 02/25/2025 11:51 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/
DIRECTOR:		MARTIN, CHERRYFACILITY TYPE:
735
ADDRESS:12295 ANDREA DRIVETELEPHONE:
(760) 488-1602
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
02/25/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:52 AM
MET WITH:Dameon Lester- Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:07 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to conduct a health and safety check. LPA met with Assistant Administrator, Dameon Lester.

During today's visit, LPA conducted a health and safety check, reviewed facility records, and did a walk-through of the facility. LPA found the following issues:
  • Holes on the walls behind the bedroom doors of two clients bedrooms.
  • Facility has not been free of pest inside the client's bedrooms.
  • Facility did not have an active and qualified administrator during 8/25/2023 through 1/1/2025.
  • Unpaid licensing fees with a last payment of 3/17/2021.
These pose an immediate and potential health and safety risk to clients in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report, LIC809, LIC809D, and appeal rights were discussed with and provided to Assistant Administrator, Dameon Lester.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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 3
Document Has Been Signed on 02/25/2025 11:51 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/25/2025 at 10:54 AM
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: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2025
Section Cited
CCR
80036(a)

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80036(a) Licensing Fees
(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. This requirement is not met as evidenced by:
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Assistant Administrator stated that the licensees will make a payment by POC due date and will provide proof to the LPA via email by POC due date.
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Based on interview and record review, the assistant administrator did not comply with the section cited above by not making sure that the licensees paid the facility's annual fees since 3/17/2021 which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
02/26/2025
Section Cited
CCR85064(b)

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85064(b) Administrator Qualification and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.
This requirement is not met as evidenced by:
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Assistant Administrator stated that he will submit a statement of understanding addressing the plan to have an active and qualified certified administrator at all times. Assistant Administrator will submit proof to LPA via email by POC due date.
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Based on observation, interview and record review, the assistant administrator did not comply with the section cited above by not ensuring that the facility had an active and qualified administrator during 8/25/2023 through 1/1/2025 which poses an immediate 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: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/25/2025 11:51 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 02/25/2025 at 11:16 AM
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: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2025
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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Assistant Administrator patched the two client's bedroom walls with the holes behind the door. POC cleared during visit.
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Based on observation, the Assistant Administrator did not comply with the section cited above in maintaining the facility safe and in good repair by repairing the two bedroom walls with holes on it which poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/27/2025
Section Cited
CCR80087(a)(1)

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80087(a)(1) Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair.. visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidenced by:
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Assistant Administrator stated that he will have the licensees develop a plan to be able to control and eliminate the pest that appear during certain seasons. Assistant Administrator stated that the plan will be sent to the LPA via email by POC due date.
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Based on observation, the Assistant Administrator did not comply with the section cited above by maintaing the facility free of pest 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: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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