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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881022
Report Date: 03/20/2024
Date Signed: 03/20/2024 10:44:03 AM


Document Has Been Signed on 03/20/2024 10:44 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: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: 3DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Quenesha Pope-DSPTIME COMPLETED:
10:48 AM
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On 3/20/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with DSP, Quenesha Pope and introduced self and stated purpose of the visit. LPA was informed that there is 1 client home and 2 in program.

The facility has 4 bedrooms, 2 bathrooms, kitchen, dining area, living room, backyard, attached garage and 1 shed. LPA completed a walk through of facility, review of records, P&I audit and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 69 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 124 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, disaster plans and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no swimming pool, bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 361881022
VISIT DATE: 03/20/2024
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Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard, and one shed found. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed administrator and DSP files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed two client files for admission agreements, updated physician reports, and needs and services plans. LPA observed a client's/representative signature missing on the admission agreement and IPP not reviewed/updated annually. Technical violation issued. P & I funds were counted at random and matched with the ledger. Medication was audited and matched with MARS. LPA reviewed facility's file for fire drills, emergency disaster plan, and insurance policy. LPA observed that the emergency disaster plan was missing pages, signature and date. Technical violation issued.

No deficiencies and two technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV were discussed and copies were provided to DSP, Quenesha Pope.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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