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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881216
Report Date: 02/03/2022
Date Signed: 02/03/2022 10:57:39 AM

Document Has Been Signed on 02/03/2022 10:57 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:
02/03/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tessa RobinsonTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Melody Brown conducted an announced pre licensing visit 02/03/2022 at 10:00 AM. This is an announced Pre-Licensing visit conducted with applicant Tessa Robinson who assisted in the tour of inside and outside of facility and the evaluation. LPA Melody Brown made a second (2nd) announced prelicensing visit this date. The follow up visit was made to confirm that all corrections have been made.

The following: “(1) Obtain and post an Ombudsman poster, (2) Post Visitor Policy Procedure (3) Visitor Vaccination Verification Log (4) Personal Hygiene supplies available for all clients”

All were found to be corrected on this visit date, February 3, 2022.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.

Applicant will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report (LIC809) was left with applicant Tessa Robinson.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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