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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423474
Report Date: 11/16/2022
Date Signed: 11/16/2022 03:31:29 PM


Document Has Been Signed on 11/16/2022 03:31 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: DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Kimberly Jordan, Executive DirectorTIME COMPLETED:
03:40 PM
NARRATIVE
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On 11/16/2022, 2:29 p.m., Licensing Program Analyst (LPA) Rayshaun Nickolas conducted a case management deficiency visit. The case management visit is in response to a deficiency cited at the facility. LPA met with Executive Director Kimberly Jordan and explained the purpose of the visit.

LPA read a written statement from staff # 2 (S2), which stated that on October 25, 2022, at 4:45 a.m., S1 and S2 entered client # 1 (C1) room to wake them up and change their diaper. The written statement further indicates that C1 started yelling, “leave me alone,” because they were not ready to get out of bed. LPA interviewed S2 to authenticate their written statement, and S2 confirmed they wrote it.

Based on S2 written statement and interview, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted with Jordan and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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Document Has Been Signed on 11/16/2022 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: VALLEY CREST
FACILITY NUMBER: 366423474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited

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87468.1(a) Personal Rights of Residents in All Facilities (3)
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents...
This requirement was not met as evidenced by:
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Based on the S2 written statement and interview, the licensee did not ensure that S1 and S2 did not infringe on C1 personal rights by allowing C1 to sleep, which poses an immediate, health, safety and 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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