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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 04:15:35 PM

Document Has Been Signed on 06/22/2023 04:15 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Carolyn Taylor-AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Michelle Echeverrria conducted an unannounced case management visit to follow up on an incident report sent to licensing dated on 06/15/23. The incident involved a staff abusing the personal rights of a client. LPA met with Administrator Carolyn Taylor and explained the reason for the visit.

LPA reviewed files, interviewed clients and staff.

Due to insufficient information available at this time, this Case Management needs further investigation. LPA conducted an exit interview where this report was discussed with the Administrator. A copy of this report was provided to the Administrator, Carolyn Taylor at the conclusion of the visit.
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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