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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880954
Report Date: 06/14/2023
Date Signed: 06/14/2023 11:41:13 AM


Document Has Been Signed on 06/14/2023 11:41 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:GRACEFUL ASSISTED LIVINGFACILITY NUMBER:
361880954
ADMINISTRATOR:VELAZQUEZ, JESSICAFACILITY TYPE:
740
ADDRESS:12253 SILVER ARROW WAYTELEPHONE:
(760) 508-2426
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:6CENSUS: 6DATE:
06/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Vanessa Arriola-CaregiverTIME COMPLETED:
11:45 AM
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On 06/14/23, Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced POC visit in order to inspect for corrected deficiency. LPA introduced self and was granted entrance by Caregiver, Vanessa Arriola.

The Department received POC for the following citation 82702(a) as of 06/11/23; civil penalty assessed per LIC421IM. Facility was providing care to 7 residents instead of 6 residents. LPA conducted a walk through of the facility and observed 6 residents in the facility and an additional caregiver. LPA interviewed (R1) and confirmed that roommate (R2) was moved out since Friday, 06/09/23. LPA called the location where (R2) was relocated and confirmed that (R2) was moved there since 06/09/23.

An exit interview was conducted, and this report LIC809 was discussed and provided to Caregiver Vanessa Arriola.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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