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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530223
Report Date: 08/29/2024
Date Signed: 08/29/2024 09:48:10 AM

Document Has Been Signed on 08/29/2024 09:48 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:HIGH DESERT ADULT CAREFACILITY NUMBER:
365530223
ADMINISTRATOR/
DIRECTOR:		GARCIA, CRYSTALFACILITY TYPE:
735
ADDRESS:14922 LOCH LOMOND CTTELEPHONE:
(626) 825-0588
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
08/29/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Mayra Gaona-LicenseeTIME VISIT/
INSPECTION COMPLETED:
09:52 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to complete the Pre-licensing inspection. LPA met with Licensee, Mayra Gaona and Administrator, Crystal Garcia. The fire clearance was approved on 5/06/2024 for three (3) ambulatory clients and one (1) nonambulatory client.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining area, living room, family room, backyard with two (2) sheds, 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 107.5 degrees F. There was a locked and secured closet where files, 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. The facility has a supply of activities for the clients.

Laundry Room/ Garage: The laundry room is inside the garage.



Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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: HIGH DESERT ADULT CARE
FACILITY NUMBER: 365530223
VISIT DATE: 08/29/2024
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Backyard: There are 2 sheds used for storage and no bodies of water in the backyard. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There is one 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 emergency/disaster plans, 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 a functioning land line and telephone for clients use.

Pre-Licensing and Comp III are complete and ready for licensure.


An exit interview was conducted, and this report was discussed and provided to Licensee, Mayra Gaona.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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