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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366403943
Report Date: 07/15/2024
Date Signed: 07/15/2024 10:36:15 AM

Document Has Been Signed on 07/15/2024 10:36 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:S.V.S. VICTORVILLE ADULT DAY CARE FACILITYFACILITY NUMBER:
366403943
ADMINISTRATOR/
DIRECTOR:		CAROLYN TAYLORFACILITY TYPE:
775
ADDRESS:15387 CHOLAME ROADTELEPHONE:
(760) 955-7535
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 75CENSUS: 57DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Carolyn Taylor-AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:44 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced required Annual Inspection. LPA met with Administrator, Carolyn Taylor. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to the following:

LPA inspected the facility inside and outside. LPA observed all passageways are clear of obstructions. The facility is maintained at a comfortable temperature of 73 degrees fahrenheit. LPA inspected client activity rooms; they are equipped with required furniture and activity supplies for clients. LPA inspected client bathrooms; bathroom appliances were operating in good and sanitary conditions. LPA observed grab bars in the bathrooms. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 107.8 degrees fahrenheit. Disinfectants, toxins, sharps and cleaning supplies are locked and inaccessible to clients. There are no firearms/ammunition or bodies of water.

At Day Program, clients are responsible to bring their own snacks and lunch. LPA observed the kitchen area to be clean, free of odors, and in a healthful manner.

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.

The last fire drill was conducted on 6/26/24. The last Fire Department inspection was conducted on 03/18/24 during today's annual inspection.

LPA reviewed five (5) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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: S.V.S. VICTORVILLE ADULT DAY CARE FACILITY
FACILITY NUMBER: 366403943
VISIT DATE: 07/15/2024
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Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809 and LIC809C was discussed and provided to Administrator, Carolyn Taylor.

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

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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