<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426335
Report Date: 04/13/2021
Date Signed: 04/13/2021 11:38:16 AM

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
RIVERSIDE, CA 92507
FACILITY NAME:KNOLLS WEST ASSISTED LIVINGFACILITY NUMBER:
366426335
ADMINISTRATOR:TERRONSAY WHALEYFACILITY TYPE:
740
ADDRESS:16890 GREEN TREE BLVD.TELEPHONE:
(760) 245-0107
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:64CENSUS: 45DATE:
04/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Terronday WhaleyTIME COMPLETED:
11:26 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Natalie Gayoso contacted the facility via telephone to commence a case management visit due to COVID-19. LPA identified herself and discussed the purpose of the call with administrator Terronsay Whaley.

The purpose of today's visit is to follow up on Resident 1 (R1)'s death. LPA spoke with administrator to obtain additional information regarding the death. LPA requested copies of the following documents from R1's facility file: Resident ID/emergency information, admission agreement, physician's report, centrally stored log of medications, resident notes for March/April 2021, and special incident reports.

The Department is requesting copies of C1's coroner's report (if applicable) and death certificate once it becomes available. Further investigation may be required depending on the circumstances and/or cause of death.

No deficiencies were cited during this visit. An exit interview was conducted with the administrator via telephone and a copy of this report was provided to the administrator via email.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1