<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880519
Report Date: 12/02/2021
Date Signed: 12/02/2021 12:13:56 PM

Document Has Been Signed on 12/02/2021 12:13 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRAILWOOD VISTA HOMEFACILITY NUMBER:
361880519
ADMINISTRATOR:COLLINS, MARIA CRISITINAFACILITY TYPE:
735
ADDRESS:11798 TRAILWOOD STREETTELEPHONE:
(760) 981-4303
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 2DATE:
12/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Maria CollinsTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a case management visit due to a recent death of a client at the facility. LPA Williams identified herself to Administrator, Maria Collins, who was also informed of the purpose of the visit.

On November 29th 2021, the Department received an incident report regarding the death of Client #1 (C1). During today's visit, LPA Williams interviewed Staff #1 (S1) and Staff #2 (S2) regarding the details surrounding C1's death. LPA Williams also collected records that are pertinent to C1's death, including:
  • C1's Inland Regional Center Client Development Evaluation Report
  • C1's Medical Appointments
  • C1's Facility Notes
  • C1's Medication Administration Record (MAR)
  • Death Report

LPA Williams also requested additional documentation be sent to the Department; such as, the Coroner's Report and a Death Certificate upon availability.

An exit interview was conducted where this report was discussed and a copy was provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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 1