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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880946
Report Date: 03/13/2025
Date Signed: 03/13/2025 04:41:49 PM

Document Has Been Signed on 03/13/2025 04:41 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:VNL ARF INCFACILITY NUMBER:
361880946
ADMINISTRATOR/
DIRECTOR:		MICHAEL CLARKFACILITY TYPE:
735
ADDRESS:3524 ACACIA AVETELEPHONE:
(909) 726-1535
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92405
CAPACITY: 3CENSUS: 3DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator, Michael Clark TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On 03/14/2025 at 2:00 PM, Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA was greeted by a staff and gained access to the home. Licensee/Administrator Michael Clark was contacted and informed of the visit. LPA explained the purpose of the visit to Licensee/Administrator Michael Clark.

The facility has three (3) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached car port, and backyard with shed. The facility is vendorized by Inland Regional Center (IRC). LPA 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), LPA observed three (3) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 120 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, 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. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation on LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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: VNL ARF INC
FACILITY NUMBER: 361880946
VISIT DATE: 03/13/2025
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Yards/Outside: One shaded patio, two (2) side gates with self-latching handles on the right and the left side of the house that leads into the backyard, attached car port and shed in the backyard. All outdoor pathways were free of obstructions.

Food Service: LPA Small 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 reviewed three (3) client files for admission agreements, medical assessments/physician reports and Individual Program Plan (IPP). LPA observed files reviewed to be complete. LPA also reviewed staff and administrator's file for First Aid/CPR certification, CPI, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA observed files to be completed.

LPA audited three (3) clients’ medications and no issues were observed. LPA audited three (3) client's Personal and Incidental (P&I) and no issues were observed.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed, and copies were provided to Licensee/Administrator Michael Clark.

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

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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