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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530132
Report Date: 12/17/2024
Date Signed: 12/17/2024 12:16:11 PM

Document Has Been Signed on 12/17/2024 12:16 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRUST & GRACE ADULT CARE HOME 3FACILITY NUMBER:
365530132
ADMINISTRATOR/
DIRECTOR:		SMYTH, JEWELFACILITY TYPE:
735
ADDRESS:12699 ALVEDA STTELEPHONE:
(562) 310-8735
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Dameon LesterTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 12/17/2024 at 10:45AM, Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA was greeted by Licensee, Dameon Lester and gained access to the home. Licensee was informed of the purpose of the visit. LPA observed that there are currently no clients in care.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached two (2) garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA completed a walk through of the facility and a review of records..



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 68 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested between 115-121 degrees Fahrenheit. The facility is equipped with operational combined smoke and carbon monoxide detectors, a charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications will be kept in secure filing cabinets inaccessible to clients. LPA Small observed night lights in the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TRUST & GRACE ADULT CARE HOME 3
FACILITY NUMBER: 365530132
VISIT DATE: 12/17/2024
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA Small observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


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

Record Review: LPA Small reviewed licensee's and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result.

No deficiencies was cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed, and copies were provided to Licensee Dameon Lester.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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