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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800135
Report Date: 08/20/2021
Date Signed: 08/20/2021 10:51:16 AM

Document Has Been Signed on 08/20/2021 10:51 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VICNELL RESIDENTIAL HOME IFACILITY NUMBER:
361800135
ADMINISTRATOR:DAVIS, VICTOR BFACILITY TYPE:
735
ADDRESS:14155 ESTATE WAYTELEPHONE:
(760) 881-3249
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 3CENSUS: 0DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Victor Davis, LicenseeTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit for the purpose of an annual inspection. LPA Gardner met with Licensee Victor Davis. This facility is a one story, 3 bedroom 2 bathroom home.

LPA Gardner toured the facility and found that the home is licensed for 3 ambulatory residents, but currently has zero. Mr. Davis indicated that he has closed his doors for operation, but wants to maintain his license. He has no residents currently living at this facility.

LPA Gardner found that each bedroom is properly furnished with amble lighting, as well as a dresser. The shower in the bathrooms have non-skid mats for resident use. The toilets and showers were functional. The kitchen area is well clean, and the sharp knives, are locked via a magnet key. The cleaners are kept under the kitchen sink and secured with a padlock. LPA Gardner observed non-perishable food items in the cabinet and together with the food items in the garage, there is a 7 day supply. LPA Gardner observed sufficient paper supply including paper towels, as well as toilet paper. Due to their being no residents and no person living at the facility, no perishable items were observed. A 30 day supply of emergency food items and water was observed in the garage.

The backyard is completely fenced with gate that opens via an unlocked latch. The backyard has shade area for residents if/when they return. The facility has a charged fire extinguisher that is located inside the kitchen. The facility has a good supply of Personal Protective Equipment.

LPA Gardner discussed the infection control practices during the visit, and an exit interview was conducted. A copy of this report was given to Mr. Davis.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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