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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800459
Report Date: 04/11/2022
Date Signed: 04/11/2022 10:31:13 AM

Document Has Been Signed on 04/11/2022 10:31 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
, CA 92507
FACILITY NAME:JOHN A. CUTSHALL ARF IIFACILITY NUMBER:
361800459
ADMINISTRATOR:CUTSHALL, JOHN AFACILITY TYPE:
735
ADDRESS:12221 MARTINIQUE STREETTELEPHONE:
(760) 867-4145
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 2DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Heather CutshallTIME COMPLETED:
10:47 AM
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Licensing Program Analysts (LPAs) Jennifer Semin and Rayshaun Nickolas arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with House Manger Heather Cutshall advised her of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.
LPAs went over COVID-19 best practices for infection control and prevention with Ms. Cutshall who is successfully incorporating the facility's Mitigation Plan. Clients have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPAs observed the facility to have multiple postings throughout the facility and for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.
LPAs requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed a storage area for storing all PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to clients. LPAs and Ms. Cutshall discussed the need to procure additional gowns and N95 masks. A Technical Assistance Advisory Note will be issued.
LPAs and Mr. Cutshall discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room.
LPAs inquired as to if staff have been fit tested for N95 masks, and Ms. Cutshall stated she nor her staff have been fit tested yet. LPA and Mr. Cutshall discussed PIN 21-10-ASC which contains resources for getting staff fit tested for N95 masks. A Technical Assistance Advisory Note will be issued.
No deficiencies were observed during today's visit.

An exit interview was conducted, and this report was discussed and provided to Ms. Cutshall along with LIC9102 TA Advisory Notes.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2022
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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