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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880567
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:45:02 PM

Document Has Been Signed on 10/27/2022 02:45 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: 3DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Michelle Stoe, DSPTIME COMPLETED:
02:47 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate a complaint investigation. LPA initially met with DSP Michelle Stoe.

During today's investigation, LPA discovered an incident regarding Client 1 (C1). LPA Bueno reviewed C1's records and LPA phoned licensee Dianna Rojas who stated that the incident occurred on 10/18/22. Licensee stated that local law enforcement was called to the home and C1 was removed from the home. Staff interviews confirmed that C1 has not returned to the home to date. Licensee informed LPA that the incident report was electronically faxed to the Department and Inland Regional Center on 10/19/22. LPA Bueno requested for Licensee to resend the incident report to the Department.

No deficiencies were cited during today's visit. An exit interview was conducted where a copy of this report was discussed with and provided to DSP Stoe.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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