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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366403943
Report Date: 09/16/2024
Date Signed: 09/16/2024 11:47:28 AM

Document Has Been Signed on 09/16/2024 11:47 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: 60DATE:
09/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Carolyn Taylor-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20240911144412. LPA met with Administrator, Carolyn Taylor.

During today's visit, LPA conducted interviews with staff, obtained and reviewed facility records. LPA found the following issue:
  • Facility staff did not submit a written report of unusual incident which threaten the physical, or emotional health or safety of any client.
This poses a potential health, safety or personal rights risk to persons in care. Refer to LIC 809D for deficiency cited.

An exit interview was conducted where this report, LIC809, LIC809D, and appeal rights were discussed with and provided to Administrator, Carolyn Taylor.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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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Document Has Been Signed on 09/16/2024 11:47 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 09/16/2024 at 11:20 AM
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: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2024
Section Cited
CCR
82061(a)(1)(D)

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82061(a)(1)(D) Reporting Requirements
(a) Upon the occurrence, during the hours the... of the event. (1) Events reported shall include, but not be limited to, the following: (D) Any unusual incident which threatens the physical or emotional health or safety of any client; This requirement is not met as evidenced by:
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Administrator stated that she will submit a statement of understanding on regulation cited and provide a copy to LPA. POC received and clear.
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Based on observation, interview and record review, the administrator did not comply with the section cited above in submitting a written special incident report to the regional office which poses a potential health, safety or personal rights risk to persons in care.
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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: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


LIC809 (FAS) - (06/04)
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