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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426348
Report Date: 06/26/2026
Date Signed: 06/26/2026 11:37:14 AM

Document Has Been Signed on 06/26/2026 11:37 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SAFEGUARD ADULT HOME IFACILITY NUMBER:
366426348
ADMINISTRATOR/
DIRECTOR:		BAYSINGER, ROYFACILITY TYPE:
735
ADDRESS:12779 2ND AVENUETELEPHONE:
(951) 544-2135
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6CENSUS: 3DATE:
06/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Roy Baysinger AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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On 6/26/2026 at 9:00 AM, Licensing Program Analysts (LPAs) Eldin Serrano and Matthew Aguilar conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA was greeted by Administrator Roy Baysinger and gained access to the home. LPAs explained the purpose of the visit to Administrator Roy Baysinger.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility is licensed for 6 of which can be ambulatory. LPAs completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA observed one client during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 105.2 degrees Fahrenheit. The facility is equipped with operational smoke detectors and 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, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food. LPAs observed facility needs more emergency water. Technical violations issued. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: SAFEGUARD ADULT HOME I
FACILITY NUMBER: 366426348
VISIT DATE: 06/26/2026
NARRATIVE
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Yards/Outside: One shaded patio, two (2) side gates with self-latching handle on both side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA 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: LPAs reviewed two (2) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs observed client#1 (C1) do not have an updated physician report. Deficiency issued. LPAs observed that client#2 (C2) do not have an updated IPP report. Deficiency issued. LPAs also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result and observed files were complete.

LPA audited two (2) clients’ medications and no issues were observed. LPA audited two (2) clients’ Personal and Incidental (P&I) and no issues observed.

Two (2) deficiencies and a technical violation were cited during this visit per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and LIC9102 were discussed, and copies were provided to Administrator Roy Baysinger.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/26/2026 11:37 AM - It Cannot Be Edited


Created By: Eldin Serrano On 06/26/2026 at 11:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAFEGUARD ADULT HOME I
FACILITY NUMBER: 366426348

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1507(c)(1)(A)
General Provisions
(1) For regional center clients the following shall apply: (A) An individualized health care plan, which may be part of a client's individual program plan, shall be prepared for each client by a health care team that shall include the client or his or her designee if the client is not able to participate in planning his or her health care, the client's primary care physician or nurse practitioner or other health care professional designated by the physician or nurse practitioner, the licensee or licensee's designee, any involved social worker or regional center worker, and any health care professional designated to monitor the client's individualized health care plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring that client#2 (C2) has an updated IPP report on file for review.which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee will provide a copy of the updated IPP on plan of correction (POC) due date.
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring that clien t #1 (C1) has an updated physicians report available for review at the time of the visit. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Licensee will provide an updated physicians report on plan of correction (POC) due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Eldin Serrano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2026


LIC809 (FAS) - (06/04)
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