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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366403943
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:10:35 PM

Document Has Been Signed on 06/22/2023 04:10 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:S.V.S. VICTORVILLE ADULT DAY CARE FACILITYFACILITY NUMBER:
366403943
ADMINISTRATOR:CAROLYN TAYLORFACILITY TYPE:
775
ADDRESS:15387 CHOLAME ROADTELEPHONE:
(760) 955-7535
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 75CENSUS: 57DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Carolyn Taylor-AdministratorTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced required Annual Inspection. LPA met with Administrator, Carolyn Taylor.

LPA inspected the facility inside and outside. LPA observed all passageways are clear of obstructions. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected client activity rooms; they are equipped with required furniture and activity supplies for clients. LPA observed grab bars in the bathrooms. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 112.3 degrees fahrenheit. Disinfectants, toxins and cleaning supplies are locked and inaccessible to clients. There are no firearms/ammunition or bodies of water.

Clients bring own lunch and snacks to the facility. LPA observed the kitchen area to be clean, free of odors, and in a healthful manner. No sharps or knives were present.

LPA observed sufficient staff present for the number of clients in care. Day program does not administer medication and no medication is stored at the facility. LPA observed fire extinguishers, smoke alarms, carbon monoxide alarms, and first aid kit in the facility. LPA reviewed the facility fire/disaster drill log. The last fire drill was conducted on 5/16/23. The last Fire Department inspection was conducted on 08/18/22.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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Document Has Been Signed on 06/22/2023 04:10 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/22/2023 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: S.V.S. VICTORVILLE ADULT DAY CARE FACILITY
FACILITY NUMBER: 366403943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in requesting a transfer of a criminal record clearance for 3 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Administrator stated that she will submit a request of transfer of a criminal record clearance for the 3 staff and provide proof of completion to LPA by POC due date by email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2023 04:10 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/22/2023 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: S.V.S. VICTORVILLE ADULT DAY CARE FACILITY
FACILITY NUMBER: 366403943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not comply with the section cited above in having a physician's report for one of the clients in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Administrator will obtain a complete LIC602, physician's report for client. Administrator will submit a copy via email to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


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: S.V.S. VICTORVILLE ADULT DAY CARE FACILITY
FACILITY NUMBER: 366403943
VISIT DATE: 06/22/2023
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 Facility has sufficient care staff for coverage. LPA reviewed 5 staff records for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA observed training certificate incomplete for one staff. Technical violation issued. LPA also observed that 3 staff have criminal record clearance yet are not associated to the facility. Deficiency with civil penalty issued. LPA reviewed 5 client files for admission agreements, updated physician reports, and needs and services plans. LPA observed the LIC602, physician's report, missing for one of the clients. Deficiency issued. LPA observed the admission agreement not signed for a different client. Technical violation issued.

Based on the observations made during today’s visit, deficiencies, technical violations and civil penalties were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIC809C, LIC809D, LIC9102, LIC421BG, and appeal rights were discussed and provided to Administrator Carolyn Taylor .

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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