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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530058
Report Date: 01/16/2025
Date Signed: 01/16/2025 12:37:35 PM

Document Has Been Signed on 01/16/2025 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JOHN A. CUTSHALL ARF 3FACILITY NUMBER:
365530058
ADMINISTRATOR/
DIRECTOR:		VEGA, JESSICA M.FACILITY TYPE:
735
ADDRESS:13474 GRAYSTONE LN.TELEPHONE:
(760) 596-1941
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 3CENSUS: 3DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Austin Cutshall, DSPTIME VISIT/
INSPECTION COMPLETED:
12:36 PM
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On 01/16/2025 at 9:35 AM, Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA was greeted by a staff and gained access to the home. LPA explained the purpose of the visit to DSP, Austin Cutshall.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached three (3) garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA completed a walk through of the facility, review of records, medications audit and Personal and Incidentals (P&I).



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA observed one (1) client during the visit. Two (2) clients’ out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 114 degrees Fahrenheit. The facility is equipped with operational smoke detectors, four (4) carbon monoxide detectors, two (2) charged fire extinguishers, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in a lock box in the pantry closet in the kitchen,
inaccessible to clients in care. LPA observed overhead lights in the hallway leading to shared bathroom. Administrator will provide nightlights for the bathroom. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JOHN A. CUTSHALL ARF 3
FACILITY NUMBER: 365530058
VISIT DATE: 01/16/2025
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Yards/Outside: One shaded patio, two (2) side gates with self-latching handle on the right and left side of the house that leads into the backyard, attached three (3) car garage, one shed with flooring supplies observed. All outdoor pathways were free of obstructions.

Food Service: LPA Small observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed three (3) client files for admission agreements, medical assessments/physician reports and Individual Program Plan (IPP). LPA observed files reviewed were complete. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result.

LPA Small audited three (3) clients’ medications and no issues were observed. LPA audited three (3) client's Personal and Incidentals (P&I) and no issues observed.

No deficiencies was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and Techinical Assistance were discussed, and copies were provided to DSP, Austin Cutshall.


SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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