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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800135
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:00:03 PM

Document Has Been Signed on 10/17/2024 12:00 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VICNELL RESIDENTIAL HOME IFACILITY NUMBER:
361800135
ADMINISTRATOR/
DIRECTOR:		DAVIS, VICTOR BFACILITY TYPE:
735
ADDRESS:14155 ESTATE WAYTELEPHONE:
(760) 881-3249
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 3CENSUS: 2DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Ariana Torres, House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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On 10/17/2024 at 10:02AM, Licensing Program Analysts (LPA) Renese Howell-Small and Magda Malcore conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA’s Small and Malcore were greeted by House Manager, Ariana Torres and gained access to the home. Licensee/Administrator Victor Davis was contacted and informed of the visit. LPA’s Small and Malcore explained the purpose of the visit to Licensee/Administrator Victor Davis.

The facility has three (3) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA’s Small and Malcore completed a walk through of the facility, review of records, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Small and Malcore observed one(_1) client during the visit. One (1) clients’ out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPA’s Small and Malcore inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA’s Small and Malcore inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 117 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detector, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA’s Small and Malcore observed night lights in the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VICNELL RESIDENTIAL HOME I
FACILITY NUMBER: 361800135
VISIT DATE: 10/17/2024
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 *** Continuation in LIC809C ***

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached one (1) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA’s Small and Malcore observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA’s Small and Malcore reviewed two (2) client files for admission agreements, medical assessments/physician reports and Individual Program Plan (IPP). LPA’s Small and Malcore observed files reviewed were complete. LPA’s Small and Malcore also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA’s Small and Malcore observed staff files to be complete.

LPAs Small and Malcore audited two (2) clients’ medications and no issues were observed. LPA’s Small and Malcore audited two (2) client's Personal and Incidental (P&I) and no issues observed.

There were two Technical Assistance given regarding Emergency Disaster plan during this visit. An exit interview was conducted where this report LIC809, LIC809C, Technical Assistance, and (Appeal Rights) were discussed, and copies were provided to House Manager, Ariana Torres.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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