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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426335
Report Date: 06/08/2021
Date Signed: 06/08/2021 03:02:42 PM

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: 51DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Terry WhaleyTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Natalie Gayoso made an unannounced visit to facility to conduct an annual inspection, with emphasis on infection control. LPA met with administrator Terry Whaley and explained the purpose of today’s visit. Administrator accompanied LPA on a tour of the inside and outside of the facility.

During today’s visit, LPA made observation pertaining to the facility’s current infection control measures. LPA observed a screening area, proper signage throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a 30+ day supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, no deficiencies were cited.
An exit interview was conducted, and a copy of this report was provided to the administrator.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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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