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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401747
Report Date: 10/18/2023
Date Signed: 10/18/2023 11:20:53 AM

Document Has Been Signed on 10/18/2023 11:20 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
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME:TRINITY - APPLE VALLEYFACILITY NUMBER:
366401747
ADMINISTRATOR:GIL QUINBARFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 16CENSUS: 15DATE:
10/18/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Elizabeth TamoushTIME COMPLETED:
11:32 AM
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On October 18, 2023, at 9:20 AM, Licensing Program Analyst (LPA), Michael Almaraz, conducted an unannounced inspection and met with Campus Director Elizabeth Tamoush. The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on October 5, 2023. LPA already completed the Physical Plant, Disaster Preparedness, and Client Records review.

During this annual inspection continuation LPA reviewed Core/Therapeutic Services, Operational Requirements, Emergency Intervention Plan, and Staffing Records. LPA reviewed six personnel files to ensure they contained all required documentation per Title 22 Regulations and Interim Licensing Standards (ILS). All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel files were locked in the staff office.

LPA reviewed the Personnel Report (LIC 500) and schedules to ensure appropriate staffing ratios.

LPA M. Almaraz conducted interviews with four available staff. Staff was able to provide sufficient information in relation to the facility's STRTP Program Statement, Emergency Intervention Plan, clients’ Needs and Services plan, and Reporting Requirements. Based on interviews with staff, the facility appears to be meeting Core Services/Supports requirements.

Based on the facility inspection and file reviews on this date, no deficiencies were cited. Facility appears to be meeting the terms and conditions of their license. An exit interview conducted and a copy of the LIC 809 was provided and explained to Elizabeth Tamoush.
SUPERVISORS NAME: Abdoulaye Traore
LICENSING EVALUATOR NAME: Michael Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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