<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880954
Report Date: 08/10/2023
Date Signed: 08/10/2023 12:02:26 PM


Document Has Been Signed on 08/10/2023 12:02 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,
, CA



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:
08/10/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vanessa Arriola, CaregiverTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a collateral visit related to an investigation (#18-AS-20210422134315) concerning a different facility. LPA met with Caregiver Vanessa Arriola and explained the purpose of the visit.

During today's visit, LPA interviewed and reviewed records pertaining to Resident #1 (R1) who previously resided at the facility being investigated.

An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1