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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881216
Report Date: 01/06/2022
Date Signed: 01/06/2022 11:14:56 AM

Document Has Been Signed on 01/06/2022 11:14 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:DYNELL'S GUEST HOME #1FACILITY NUMBER:
361881216
ADMINISTRATOR:ROBINSON, CHARLESFACILITY TYPE:
735
ADDRESS:12423 FELIPE DRIVETELEPHONE:
(761) 900-5089
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 0DATE:
01/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Charles Fisher - RobinsonTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility to conduct a Pre-licensing inspection for the above facility. LPA met with Applicant/Administrator Charles
Fisher - Robinson. Applicant/Administrator Robinson has applied for an Adult Residential Care Facility. The Fire Safety Inspection was approved on December 13, 2021 for four (6) Ambulatory Adult Clients. LPA Brown observed the following:
Structure:
Facility was a one-story house with four (4) resident bedrooms, and one (1) staff bedroom and two (2) resident/staff bathroom, living room, family rrom, dining area and kitchen. There was an attached two (2) car garage in the left side of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #1, #2, #3 and #4 will accommodate ambulatory resident. 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The (2) resident/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition.

(CONTINUED ON LIC 809C)

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DYNELL'S GUEST HOME #1
FACILITY NUMBER: 361881216
VISIT DATE: 01/06/2022
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There is sufficient storage for perishable food. At 09:55 AM, LPA Brown tested the water temperature in the kitchen. LPA Brown verified water temperature was measured at 107 degrees Fahrenheit. There was adequate seating for meals for all clients. Laundry room with washer and dryer and laundry detergents and cleaning supplies were observed locked away from clients.
Living/Family room:
There was a living/family room with adequate seating for all clients and a television.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
One (1) Patio furniture for outdoor seating observed. Self-latching handle on the left side of the house that leads into the backyard. There is a gate/door on the left side with exit into the front of the house. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the living room and none in the entry hallway. There’s a Let-Us-No poster observed but no Ombudsman Poster.
General items:
One (1) fire extinguisher was charged and located in the kitchen. Eight (8) smoke detectors and one (1) carbon monoxide were tested and observed to be in working order. Client records will be stored in a locked filing cabinet in the office. First Aid kit with required components, and locked area for medication storage was observed. LPA Brown observed a facility phone and Applicant/Administrator Robinson provided facility phone number 760-955-9393. There is enough Emergency water supply observed and the required 72-hour emergency food supply. Component III was completed on this day as well.

Pre-Licensing is incomplete and the following deficiencies to be resolved by 01//19/2022 at 10:00 AM:
Obtain and post an Ombudsman poster
Post Visitor Policy Procedure
Visitor Vaccination Verification Log
Personal Hygiene supplies available for all clients


A follow up Pre-Licensure LIC809 will be generated upon resolution of deficiencies. This report (LIC 809) was reviewed and copy of report provided to Applicant/Administrator Charles Fisher-Robinson.



SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC809 (FAS) - (06/04)
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