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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530058
Report Date: 09/25/2023
Date Signed: 09/25/2023 11:52:09 AM

Document Has Been Signed on 09/25/2023 11:52 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: 2DATE:
09/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:John Cutshall-LicenseeTIME COMPLETED:
11:55 AM
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On 9/25/23 at 11:30 AM, 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 Cutshall.

Per the LIC200, John requested for the capacity increase from two (2) ambulatory to three (3) ambulatory. The fire clearance request was approved on 08/08/2023 for three (3) ambulatory clients.

There is a facility sketch on file with designation of capacity for each room. The licensee was advised that the noted designated capacity for each room is to remain in compliance.

LPA observed that the client bedrooms were appropriately furnished and had functional lighting. The physical plant is ready for an increase in capacity. LPA will update the facility's file and issue a new license stating change in capacity.

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

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
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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