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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800193
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:45:43 PM

Document Has Been Signed on 11/21/2023 02:45 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TRUST & GRACE ADULT CARE HOMEFACILITY NUMBER:
361800193
ADMINISTRATOR:MARTIN, CHERRYFACILITY TYPE:
735
ADDRESS:12295 ANDREA DRIVETELEPHONE:
(760) 488-1602
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 3DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Dameon Lester- DSPTIME COMPLETED:
02:56 PM
NARRATIVE
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On 11/21/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA introduced self and stated the purpose of the visit to DSP, Dameon Lester. LPA toured the facility with DSP.

The facility has 4 bedrooms, 3 bathrooms, a kitchen, dining area, living room, family room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA conducted 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 73 degrees Fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed that there is an insufficient supply of linens. Deficiency issued. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet, which tested within regulation at 110.8 degrees Fahrenheit. The facility is equipped with operational phone, fire extinguishers, smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and emergency disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. LPA observed medication stored inside the refrigerator. Deficiency issued. There was a designated locked storage space for client/staff files, first aid kit and medication. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Yards/Outside: One shaded patio, a side gate on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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 6
Document Has Been Signed on 11/21/2023 02:45 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2023 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in making medication inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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DSP immediately made the medication inaccessible. Administrator stated that a lock box will be purchased for the medication that needs to be kept refrigerated and submit a picture of box and receipt to LPA via email by POC due date.
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in providing criminal record clearance for one staff that was employed for over a year which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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DSP stated that staff stopped working at the facility in the beginning of the year. Administrator stated that a statement of understanding will be submitted to LPA via email by 12/05/23 on regulation CCR 80019(e).
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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/21/2023 02:45 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2023 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the administrator did not comply with the section cited above in providing an Infection Control Plan for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Administrator stated that an Infection Control Plan will be submitted to the LPA via email by POC due date.
Type B
Section Cited
CCR
85088(c)(4)(A)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (A) The quantity of linen provided shall permit changing the linen at least once each week or more often when necessary to ensure that clean linen is in use by clients at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in maintaining a sufficient supply of clean linens for clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Administrator stated that sufficient clean linens will be purchased for each client and a copy of receipt and picture of product will be sent to LPA via email by POC due date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/21/2023 02:45 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2023 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in reporting to the RO of the death report of a previous client which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Administrator stated that training will be conducted with all staff on regulation CCR 80061(b) and submit proof of attendance to LPA via email by POC due date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in maintaining complete personnel records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Administrator stated that a statement of understanding will be submitted to LPA via email by POC due date on regulation CCR 80066(a).
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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/21/2023 02:45 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 11/21/2023 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in performing emergency drills during each shift which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Administrator stated that training will be held with staff going over regulation HSC 1565(c) and submit proof of attendance to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


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: TRUST & GRACE ADULT CARE HOME
FACILITY NUMBER: 361800193
VISIT DATE: 11/21/2023
NARRATIVE
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Food Service: Non-perishable and perishable food supply is sufficient for future clients in care. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed the administrator and one staff file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed an incomplete personnel files. Deficiency issued. LPA observed that one staff file did not have criminal record clearance. Deficiency with civil penalty issued. LPA observed no proof of an Infection Control Plan. Deficiency issued. LPA observed that the facility has performed emergency disaster drills during each shift. Deficiency issued. LPA reviewed two client files for admission agreements, updated physician reports, and needs and services plans. P & I funds was audited and matched with records. LPA observed that the facility has failed to report to the RO about incidents and death reports. Deficiency issued.

Deficiencies and civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and copies were provided to DSP, Dameon Lester.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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