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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530058
Report Date: 01/17/2023
Date Signed: 01/17/2023 10:21:49 AM

Document Has Been Signed on 01/17/2023 10:21 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JOHN A. CUTSHALL ARF 3FACILITY NUMBER:
365530058
ADMINISTRATOR:VEGA, JESSICA M.FACILITY TYPE:
735
ADDRESS:13474 GRAYSTONE LN.TELEPHONE:
(760) 596-1941
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 2CENSUS: 0DATE:
01/17/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:John A CutshallTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPA) Paola Guerrero made an announced pre-licensing visit to facility LPA met with Licensee John A. Cutshall. The pending application is for Adult Residential Facility (ARF). There are currently zero (0) clients in care. The Administrator accompanied LPA on a tour of the inside and outside of the facility. The home is a five (5) bedroom, three (3) bathroom home with a living room, dining room, kitchen, attached garage, and game room. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms, or ammunition. All bedrooms are furnished with a bed, night stand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, shower and tubs are in good repair and have non-skid mats. LPA measured and observed the water temperatures in the Kitchen to be at 110.7 degrees F. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The backyard is completely enclosed with functioning gate to exit to front yard. The outdoor space is suitable for client use. LPA observed fully charged fire extinguisher present in the facility. Smoke alarms and carbon monoxide are present and functional. Medications are stored and secured in a locked cabinet inside a lock box in kitchen pantry and inaccessible to clients. The facility has a designated area for staff and client records. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the clients.

Pre-licensing inspection is complete, and no corrections are needed to be made. The Comp III presentation was completed during today's visit.

An exit interview was conducted, and a copy of this report was provided to the Licensee John A. Cutshall.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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