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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530070
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:47:18 PM

Document Has Been Signed on 05/15/2024 04:47 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:ETERNITY LOVE RESIDENTIAL FACILITY, LLCFACILITY NUMBER:
365530070
ADMINISTRATOR/
DIRECTOR:		CLARKE, NOELLEFACILITY TYPE:
735
ADDRESS:14753 LADYBIRD LANETELEPHONE:
(949) 668-5421
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 2DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:36 PM
MET WITH:Noelle Clarke- AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced case management visit to follow up on an incident report sent to licensing on 5/09/24. LPA introduced self and stated the purpose of the visit to Administrator, Noelle Clarke.

During today's visit, LPA performed a health and safety check, reviewed records and interviewed staff. Interview revealed that staff did not accord a client's safety during an outing event.

One deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were discussed and provided to Noelle Clarke.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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Document Has Been Signed on 05/15/2024 04:47 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/15/2024 at 04:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ETERNITY LOVE RESIDENTIAL FACILITY, LLC
FACILITY NUMBER: 365530070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
80072(a)(2)

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80072(a)(2) Personal Rights
(a) Except for children’s residential facilities, each...not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
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Administrator stated that she will review regulation cited and submit a statement of understanding to LPA via email by POC due date.
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Based on interview and record review, the administrator did not comply with the section cited above in according a client's safety by abandoning the client in the park in the evening which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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