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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530089
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:31:07 AM

Document Has Been Signed on 08/08/2024 10:31 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRUST & GRACE ADULT CARE HOME #4FACILITY NUMBER:
365530089
ADMINISTRATOR/
DIRECTOR:
AL'AZIZ, DAMENFACILITY TYPE:
735
ADDRESS:14951 CHRISTOPHER STREETTELEPHONE:
(561) 441-2432
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 3CENSUS: 0DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Administrator Damen AlazizTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an announced visit to the facility to conduct a required comprehensive annual inspection. LPA was greeted and granted entry by the Administrator Damen Alaziz.

The facility is an Adult Residential Facility (ARF) with a license capacity of (3) and current census of (0) clients. The facility is pending vendor certification through Inland Regional Center (IRC). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by the Community Care Licensing Division (CCLD). Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for client activities. The facility is maintained at a comfortable temperature. Three (3) client bedrooms inspected were furnished with clean bed linen, mattresses, night stands, chairs, storage space, and sufficient lighting. Two (2) client bathrooms were observed clean and fixtures were operating properly. The hot water temperatures in the bathrooms measured 105 and 107 degrees F. The facility maintains a sufficient supply of bed linen, and towels. The facility has a locked cabinet where medications will be centrally stored. The facility is equipped with operating laundry equipment, telephone service, and a centralized fire/carbon monoxide system. Posters such as client personal rights, the Community Care Licensing complaint poster, house rules, and facility license were posted in a common area. Cleaning supplies and toxins were kept locked.

Food Service: Kitchen and dining areas were maintained clean. The facility has a sufficient space for non-perishable and perishable foods. The facility refrigerator and freezer were maintained in healthful manner.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TRUST & GRACE ADULT CARE HOME #4
FACILITY NUMBER: 365530089
VISIT DATE: 08/08/2024
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Overall the facility is maintained clean and in good repair. No deficiencies were cited during today's inspection.

An exit interview was conducted where this report was discussed and a copy provided to Administrator Damen Alaziz at the conclusion of the visit,

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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