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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800427
Report Date: 07/26/2023
Date Signed: 07/26/2023 10:11:38 AM

Document Has Been Signed on 07/26/2023 10:11 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: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:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Amy Narasky-LicenseeTIME COMPLETED:
10:20 AM
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On 07/26/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Licensee, Amy Narasky, and introduced self and stated the purpose of the visit. LPA was informed that there are currently 2 clients in care who are in day program.

The facility has 2 client bedrooms, 1 client bathroom, 3 staff bedrooms, 1 staff bathroom, living room, kitchen, dining area, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees farenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathroom; bathroom was clean and appliances were found functional. Water temperature tested at 105.4 degrees farenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and one charged fire extinguisher. Posters such as; the personal rights and disaster plans were posted in a common area. LPA observed the Emergency disaster plan last reviewed on 08/01/2020. Technical violatio issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets and drawers inaccessible to clients. There was a designated storage space for clients/staff files. Medication, first aid kit and emergency disaster kits were observed in secure cabinets inaccessible to clients. There are no pools or bodies of water. Firearms and ammunition are kept locked and secured inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AMY NARASKY ARF
FACILITY NUMBER: 361800427
VISIT DATE: 07/26/2023
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Yards/Outside: One shaded patio, two sheds, and a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Licensee, spouse and son reside in the home.

Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed Licensee file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. The facility last conducted an earthquake and fire drill on June 10, 2023.

One technical violation and no deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV were discussed and copies were provided to the Licensee, Amy Narasky.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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