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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880954
Report Date: 08/14/2023
Date Signed: 08/14/2023 12:43:05 PM


Document Has Been Signed on 08/14/2023 12:43 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:GRACEFUL ASSISTED LIVINGFACILITY NUMBER:
361880954
ADMINISTRATOR:VELAZQUEZ, JESSICAFACILITY TYPE:
740
ADDRESS:12253 SILVER ARROW WAYTELEPHONE:
7605082426
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:6CENSUS: 6DATE:
08/14/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Vanessa Arriolagarcia, caregiverTIME COMPLETED:
12:48 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on complaint control number 56-AS-20221019114059. Complaint control number 56-AS-20221019114059 was lodged against another facility licensed by the same licensee; however, that facility is closed. LPA Nickolas met with caregiver Vanessa Arriolagarcia and explained the purpose of the visit.

An exit interview was conducted, and a copy of this report (LIC 809) provided to Arriolagarcia.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
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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