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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800427
Report Date: 06/07/2022
Date Signed: 06/07/2022 10:52:07 AM

Document Has Been Signed on 06/07/2022 10:52 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:AMY NARASKY ARFFACILITY NUMBER:
361800427
ADMINISTRATOR:NARASKY, AMYFACILITY TYPE:
735
ADDRESS:13775 KIOWA ROADTELEPHONE:
(760) 912-4921
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 2CENSUS: 2DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Licensee- Amy Narasky TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to initiate annual inspection, LPA met with Licensee- Amy Narasky

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients.

LPA toured the facility inside and out and there were no health and safety concerns. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors.

The outdoor and indoor hallways were also free of obstruction. Cleaning supplies are locked in the cabinet on the back porch. Knives are locked in the drawer on the left next to stove.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review.

The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers which have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature in the main bathroom at 118.2 degrees F. LPA observed hand sanitizer throughout the home and a 30- day supply of PPE.

Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Licensee- Amy Narasky at the conclusion of the inspection.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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