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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423474
Report Date: 10/27/2022
Date Signed: 10/27/2022 01:00:38 PM


Document Has Been Signed on 10/27/2022 01:00 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:VALLEY CRESTFACILITY NUMBER:
366423474
ADMINISTRATOR:JORDAN, KIMBERLYFACILITY TYPE:
740
ADDRESS:18524 CORWIN RDTELEPHONE:
(760) 242-3188
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:65CENSUS: 41DATE:
10/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Kimberly Jordan, Executive DirectorTIME COMPLETED:
01:06 PM
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On 10/27/2022, at 8:55 a.m., Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to conduct a Health and Safety case management visit. This case management visit is in response to a SOC 341 that was received by our agency from the facility on 10/26/2022. LPA met with Executive Director Kimberly Jordan and explained the purpose of the visit.

The SOC 341 documents personal rights violation of Client #1 (C1) by staff #1 (S1). Inquiry into this incident included conducting a tour of the facility to assess for any Health and Safety concerns. LPA reviewed the statements provided by witness #1 (W1) regarding the incident, interviewed facility staff and residents, and obtained copies of the facility file documents pertinent to the visit.

There were no health and safety concerns observed during this visit. Additional information will be required before the closure of this incident.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to Jordan
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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