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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881176
Report Date: 08/09/2024
Date Signed: 08/09/2024 12:02:03 PM

Document Has Been Signed on 08/09/2024 12:02 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:DYNELL'S GUEST HOME #2FACILITY NUMBER:
331881176
ADMINISTRATOR/
DIRECTOR:		FISHER ROBINSON,CHARLES D.FACILITY TYPE:
735
ADDRESS:12605 CASA BONITA PLACETELEPHONE:
(760) 900-5089
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 4DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ciara Delay-StaffTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analysts (LPAs) MIchelle Echeverria and Lavette Farlow arrived unannounced to conduct the required annual visit to the facility. LPAs met with staff Ciara Delay and Anthony Davis, and introduced self and stated purpose of the visit. LPAs were informed that there was 1 client home and 3 in day program.

The facility has 4 bedrooms, 4 bathrooms, 1 staff bedroom with private bathroom, kitchen, dining area, family room, living room, loft, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPAs completed a walk through of facility, review of records, medication and P&I audit.

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 of 72 degrees fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs observed the downstairs client's bedroom mattress with bad springs. Deficiency issued. LPAs observed the downstairs client's bedroom closet used as the facility's storage. Deficiency issued. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 111.4 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure and inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed secure and inaccessible to clients. The facility had emergency kits in the garage for clients in care. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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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Document Has Been Signed on 08/09/2024 12:02 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/09/2024 at 11:30 AM
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: DYNELL'S GUEST HOME #2
FACILITY NUMBER: 331881176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(4)
Building and Grounds
(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the administrator did not comply with the section cited above by using the client's bedroom closet as the facility's storage which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administrator stated that he will remove the items stored in the client's closet bedroom and submit a picture to LPA via email by POC due date.
Type B
Section Cited
CCR
85088(c)(1)
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. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the administrator did not comply with the section cited above by having a mattress with bad springs in one client's bedroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administrator stated that he will replace the client's bed mattress with a new one and submit proof of receipt and picture of mattress 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: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


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: DYNELL'S GUEST HOME #2
FACILITY NUMBER: 331881176
VISIT DATE: 08/09/2024
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Yards/Outside: LPAs observed one shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard, and fruit trees growing. All outdoor pathways were free of obstructions.

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: LPAs reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed Administrator and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds and medications were audited and appeared to be managed appropriately. The facility last conducted a disaster drill in June 5, 2024.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC809D were discussed and copies were provided to the Administrator, Charles Fisher who later arrived.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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