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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530058
Report Date: 07/25/2023
Date Signed: 07/25/2023 12:37:02 PM

Document Has Been Signed on 07/25/2023 12:37 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: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: 2DATE:
07/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:John A Cutshall-LicenseeTIME COMPLETED:
12:44 PM
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On 7/25/23, Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to the facility for the purpose of increasing the capacity. LPA was greeted and granted entrance by the Licensee, John A Cutshall.

Per the LIC200, John requested for the capacity increase from two (2) ambulatory to four (4) ambulatory on 05/03/2023. The fire clearance request was approved on 05/08/2023 for four (4) ambulatory clients.

There is a facility sketch on file with designation of capacity for each room. Per the facility sketch, bedroom #2 is for 1 client, bedroom #3 is for 2 clients and bedroom #4 is for 1 client. Licensee states that there has been a change to the facility sketch where bedroom # 3 is now for 1 client and a downstairs bedroom has been converted into a client's bedroom. LPA called and spoke to the fire inspection office where it was confirmed that the inspection was processed per the facility sketch included with the STD 850. LPA informed the Licensee that a new facility sketch and fire inspection would be required for a capacity change since there has been a change to the clients bedrooms. A subsequent visit will be conducted once the new facility sketch and fire inspection has been approved.

An exit interview was conducted where this report LIC809 was discussed and provided to the Licensee, John A Cutshall.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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