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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880646
Report Date: 02/26/2025
Date Signed: 02/26/2025 10:52:13 AM

Document Has Been Signed on 02/26/2025 10:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WHISPERING WINDS OF APPLE VALLEY ASSISTED LIVINGFACILITY NUMBER:
361880646
ADMINISTRATOR/
DIRECTOR:		JEFFERY GOLLINARFACILITY TYPE:
740
ADDRESS:11825 APPLE VALLEY ROADTELEPHONE:
(760) 961-1212
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 116CENSUS: 99DATE:
02/26/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jeff GolliharTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted a case management visit to the facility to discuss changes in bedridden status application submitted to the regional office and hospice. LPA met with Executive Director (ED), Jeff Gollihar, and informed the purpose of the visit.

During today's visit the following was discussed: amendments to Licensee's application (LIC200) for change in bedridden status to be resubmitted to Community Care Licensing Division regional office by February 28, 2025. Hospice waiver increase request to be submitted to Community Care Licensing Division regional office. ED Gollihar was provided regulations 87632 hospice waiver, 87616 exceptions for health conditions, 87633 Hospice care of terminally III residents for review and to assist with hospice waiver increase request.

Hospice waiver requests are to be submitted in writing by fax (951) 248-0370 or emailed to: cclascpsanbernardinoro@dss.ca.gov

An exit interview was conducted where this report was discussed and a copy provided to ED Gollihar as the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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