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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880646
Report Date: 11/16/2020
Date Signed: 11/16/2020 12:44:18 PM

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:WHISPERING WINDS OF APPLE VALLEY ASSISTED LIVINGFACILITY NUMBER:
361880646
ADMINISTRATOR:MONYA HENRYFACILITY TYPE:
740
ADDRESS:11825 APPLE VALLEY ROADTELEPHONE:
(760) 961-1212
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:115CENSUS: DATE:
11/16/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Monya HenryTIME COMPLETED:
11:24 AM
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Licensing Program Analyst (LPA) Kathleen Wiggins contacted the facility via telephone to commence a case management visit via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call with Administrator - Monya Henry

Based on evidence obtained during today's visit, the LPA has verified that the individual is not present, employed, or residing at the facility. The individual named in the Confirmation of Removal letter dated 09/08/2020 is Tavares Andrews.

LPA was informed by the administrator that Jackson applied to work at the facility and was pending background check clearance. Administrator stated Jackson never worked in the community. The administrator stated she understood that during this process Jackson cannot work, reside, or be present at a licensed facility.

No deficiencies were cited during this visit. An exit interview was conducted with the Administrator via telephone and copies of this report and Non-Exemptible conviction letter were provided to the Administrator via email. Report with facility representative signature was obtained. Verification of removal is complete.

SUPERVISOR'S NAME: Leslie MendivelesTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Kathleen WigginsTELEPHONE: (951) 205-7142
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
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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