365530132-11-30-2023-56-AS-MECA-CY3NCS-20231130092113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530132
Report Date: 11/30/2023
Date Signed: 11/30/2023 09:21:17 AM

Document Has Been Signed on 11/30/2023 09:21 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		FACILITY NUMBER:	365530132
ADMINISTRATOR:	SMYTH, JEWEL		FACILITY TYPE:	735
ADDRESS:	12699 ALVEDA ST		TELEPHONE:	(562) 310-8735
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92394
CAPACITY: 4		CENSUS: 0	DATE:	11/30/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Dameon Lester- Licensee		TIME COMPLETED:	09:27 AM

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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to complete the Pre-licensing inspection. LPA met with Licensees, Dameon Lester and Ashley Taylor and Administrator Jewel Smyth. The fire inspection was approved on 10/12/2023 for four (4) ambulatory clients.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry room, backyard, and attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The water temperature was measured at 114.5 degrees F. There was a locked and secured filing cabinet where medication and sharps will be stored. There was also non-perishable food inside the pantry and perishable food inside the refrigerator/freezer.

Common Sitting Areas: There is adequate seating in the common areas.

Laundry Room/ Garage: The laundry room is near the kitchen. The chemicals will be stored inside a locked inaccessible closet across.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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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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	FACILITY NUMBER: 365530132
	VISIT DATE: 11/30/2023

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Linens and Hygiene Supplies: An adequate supply of linens was available.

Backyard: There are no bodies of water in the backyard. There is a shaded table with seating for the all the clients. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There was one (1) charged fire extinguisher in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the facility sketch, complaint procedures, and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit and emergency kits. The facility has an active land line for the telephone. Facility telephone number is 760-596-0237.

Pre-Licensing and Component III are complete and facility is ready for licensure.

An exit interview was conducted, and this report was discussed and provided to Licensee, Dameon Lester.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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