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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881216
Report Date: 03/27/2023
Date Signed: 03/27/2023 12:23:12 PM

Document Has Been Signed on 03/27/2023 12:23 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, 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:
(760) 900-5089
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 0DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Charles Robinson-AdministratorTIME COMPLETED:
12:30 PM
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On 03/27/23 at 09:40 AM, Licensing Program Analysts (LPA's) Michelle Echeverria and Anna Bueno arrived at the facility unannounced to conduct a required Annual visit. LPA's were greeted by Staff, Deborah Jetter and later met with Administrator, Charles Robinson. LPA's toured the facility inside and outside with Administrator. LPA's observed that there are currently no clients admitted to the facility.

The facility has 5 bedrooms (4 clients, 1 staff), 2 bathroom (1 clients, 1 staff), a kitchen, dining area, living room, attached garage, and backyard. The facility is a specialized home pending vendorization by Inland Regional Center. LPA's conducted a general overall inspection, which included, but was not limited to, the following:
Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 73 degrees F temperature. LPA's inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. An adequate supply of linens stored in a cabinet in the main hallway of the residence. LPA's inspected client bathroom; bathroom was clean and appliances were operating appropriately. LPA's tested the water temperature in the bathroom faucet, which tested within regulation at 112 degrees F. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility had emergency supplies for future clients. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for future clients in care.
Yards/Outside:
One shaded patio furniture for outdoor seating along with three locked sheds storing furniture and gardening supplies observed. Side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DYNELL'S GUEST HOME #1
FACILITY NUMBER: 361881216
VISIT DATE: 03/27/2023
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Food Service: Non-perishable and perishable food supply is sufficient for future clients in care. Facility has a variety of food available. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
Record Review: LPA's reviewed the facility's file along with the Administrator's file for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809-C was discussed and copies were provided to the Administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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