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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880567
Report Date: 05/13/2022
Date Signed: 05/13/2022 02:31:44 PM

Document Has Been Signed on 05/13/2022 02:31 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:YUCCA RESIDENTIALFACILITY NUMBER:
361880567
ADMINISTRATOR:NICOLE JOYNERFACILITY TYPE:
735
ADDRESS:16320 YUCCA AVETELEPHONE:
(760) 843-7676
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 2DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Edraline McCraw, CaregiverTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Rohit Lama made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA was greeted and granted entrance by Edraline McCraw, Caregiver and LPA explained the purpose of today's visit. Administrator was contacted and informed of LPAs arrival.

Edraline McCraw stated that all staff and residents were fully vaccinated and there were no recent positive COVID test results nor were there any individuals currently with COVID symptoms.

During today’s visit, LPA made observation pertaining to the facility’s current infection control measures. LPA observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control.

The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and resident for COVID-19, when and how to isolate/quarantine resident, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor resident regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.



***Continuation on LIC 809-C***
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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: YUCCA RESIDENTIAL
FACILITY NUMBER: 361880567
VISIT DATE: 05/13/2022
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CONTINUED FROM LIC 809

Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was provided to Edraline McCraw at the conclusion of the inspection.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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