366426335-9-26-2024-56-AS-MECA-D8DTRF-20240822145728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426335
Report Date: 08/22/2024
Date Signed: 09/26/2024 09:13:05 AM

Document Has Been Signed on 09/26/2024 09:13 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:	KNOLLS WEST ASSISTED LIVING		FACILITY NUMBER:	366426335
ADMINISTRATOR:	TERRONSAY WHALEY		FACILITY TYPE:	740
ADDRESS:	16890 GREEN TREE BLVD.		TELEPHONE:	(760) 245-0107
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY:	64	CENSUS: 51	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Terronsay Whaley- Administrator		TIME COMPLETED:	03:10 PM

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Licensing Program Analysts (LPAs) Michelle Echeverria and Lavette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Administrator, Terronsay Whaley and caregiver, Janeth Gonzalez and were granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) licensed capacity for (64), current census (51). The facility has (32) apartment bedrooms with bathrooms included, reception area, office with medication room, employee room, laundry room, media room, theater room, activities room, kitchen, dining room and an outdoor shaded area with seating. LPAs were accompanied by the Administrator and caregiver to conduct a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 76, 74, and 75 degrees fahrenheit. Water temperature measured at 110, 111.1, 110.2, 110.9, 109.8 and 106.8 degrees fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating fire extinguishers, smoke detectors, signal alarms and carbon monoxide alarms. Posters such as personal rights, CCL complaint poster, CCL license, ombudsman, and facility sketch were posted in a common area. LPAs observed the Emergency Disaster Plan last reviewed/updated on 3/20/23 on the old form. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for residents/staff files. Medications were kept in Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KNOLLS WEST ASSISTED LIVING	FACILITY NUMBER: 366426335
	VISIT DATE: 08/22/2024

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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed (5) residents files for admission agreements, physician reports, and needs and services plans. LPA also reviewed (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were not audited due to time management. The facility last conducted a fire drill on 04/10/2024.

No deficiencies and one technical violation were cited during this visit. An exit interview was conducted, and this report LIC809, LIC809C and LIC9102TV were discussed and provided to Administrator, Terronsay Whaley.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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