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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530263
Report Date: 01/10/2025
Date Signed: 01/10/2025 11:22:08 AM

Document Has Been Signed on 01/10/2025 11:22 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VALLEY CRESTFACILITY NUMBER:
365530263
ADMINISTRATOR/
DIRECTOR:		JORDAN, KIMBERLYFACILITY TYPE:
740
ADDRESS:18524 CORWIN RDTELEPHONE:
(760) 242-3188
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 65CENSUS: 33DATE:
01/10/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Gabriel Aguilar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 01/10/2025, Licensing Program Analyst (LPA) Becky Mann conducted an announced Pre-licensing visit for a change of ownership (CHOW). LPA was greeted by Gabriel Aguilar, Administrator. LPA Introduce self and stated purpose of the visit. An initial application for change of ownership to operate a Residential Care for the Elderly Facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 11/10/2024 for a total capacity of sixty-five (65). Fire clearance was granted on 10/21/2024 for 48 non-ambulatory and 17 bedridden residents, with a total capacity of 65. LPA Mann observed the following:

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: beds, mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA verified hot water temperature was measured around 107, 112, 114 and 120 degrees Fahrenheit. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. All sharps are locked. There is a designated office for resident/staff files.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VALLEY CREST
FACILITY NUMBER: 365530263
VISIT DATE: 01/10/2025
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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

The facility was evaluated in accordance with the CCR, Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of residents in care. Facility appears to be ready for licensure.



A COMP III orientation was also conducted during today's visit.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided to Gabriel Aguilar, Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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