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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880519
Report Date: 05/24/2022
Date Signed: 05/24/2022 02:49:01 PM

Document Has Been Signed on 05/24/2022 02:49 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
, 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:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria CollinsTIME COMPLETED:
02:58 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic.

LPA Gardner met with Direct Support Staff Roberto Mungcal who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the beginning of visit there was one (1) staff and two (2) clients present. Administrator Maria Collins and Michael Collins showed up during today’s visit to complete the inspection.

LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Roberto Mungcal. LPA Gardner observed the staff member was properly fitted with a face covering. The facility was notified they need to complete a COVID-19 Mitigation Plan (LIC808) and send it to licensing. The facility notified LPA that they have a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. Clients have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, and social distancing. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the in the hall closet. The facility has a full thirty (30) day supply of PPE items such as gloves, face shields, gowns, N95 masks, disinfectant, and hand sanitizer.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: TRAILWOOD VISTA HOME
FACILITY NUMBER: 361880519
VISIT DATE: 05/24/2022
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All clients and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

During today’s visit, LPA Gardner found that Staff-S1 has not completed a criminal background clearance to work at the facility. The facility removed S1 from facility during today’s visit. The facility will be issued a type A citation and a $500-dollar civil penalty for allowing S1 to work at the facility for two (2) years without obtaining a criminal background clearance.

Based on the observations made during today’s visit, one (1) type A deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Maria Collins along with a copy of LIC809D, LIC421BG, and the appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2022 02:49 PM - It Cannot Be Edited


Created By: Ryan Gardner On 05/24/2022 at 01:44 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
, CA 92507

FACILITY NAME: TRAILWOOD VISTA HOME
FACILITY NUMBER: 361880519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
80019. Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department or.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing S1 to work in the facility for two (2) years without completing a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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The licensee has agreed to remove S1 from the facility. The licensee has agreed to not allow S1 in the facility until they complete the criminal background clearance. The licensee has agreed to read regulation 80019 entirely and send LPA self-certify letter that the regulation was read and understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
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