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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530058
Report Date: 11/25/2025
Date Signed: 11/25/2025 11:41:08 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2025 and conducted by Evaluator Renese Howell-Small
COMPLAINT CONTROL NUMBER: 56-AS-20250925143921
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:3CENSUS: 3DATE:
11/25/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Austin CutshallTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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9
The facility staff neglected to bring the client to the hospital when in pain for three days
INVESTIGATION FINDINGS:
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On 11/25/2025 at 10:45AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA discussed the purpose of the visit with staff, Austin Cutshall. The investigation consisted of interviews and record review.

In regards to the allegation of the facility staff neglected to bring the client to the hospital when in pain for three days:
LPA interviewed three (3) staff, one (1) client and the relative of Client 1 (C1). Staff stated that when C1 informs staff that they are in pain, staff administers C1's medication. C1 had a physician's appointment on 03/05/2025. Recently, C1 was taken to the physician on 10/15/2025 and for an eye exam on 11/20/2025. C1 stated that they are given their medications when needed and on a regular basis. Staff stated that there was a delay in C1's insurance, however C1 has consistenly received their medication.
Based on interviews and record review, this allegation is UNSUBSTANTIATED.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20250925143921
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/25/2025
NARRATIVE
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UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and copies were provided to staff, Austin Cutshall.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2