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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881022
Report Date: 11/01/2023
Date Signed: 11/01/2023 04:06:05 PM

Document Has Been Signed on 11/01/2023 04:06 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRUST & GRACE ADULT CARE HOME #2FACILITY NUMBER:
361881022
ADMINISTRATOR:JEWEL A SMYTHFACILITY TYPE:
735
ADDRESS:14735 CEREZO ROADTELEPHONE:
(562) 883-3413
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
11/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Quenesha Pope- Assistant House ManagerTIME COMPLETED:
04:10 PM
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Licensing Program Analyst, Michelle Echeverria, (LPA) arrived at Trust & Grace Adult Care Home #2, unannounced to conduct a Case Management Visit for health and safety. This case management visit is in response to a Special Incident Report, (SIR) submitted to the Community Care Licensing Office on 10/12/23. LPA was greeted by Assistant House Manager Quenesha Pope at the front door and granted entrance. LPA introduced self and stated purpose of the visit.

During today's visit, LPA conducted a health and safety check and conducted interviews with staff and clients.

No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to Assistant House Manager Quenesha Pope.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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