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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800427
Report Date: 07/26/2024
Date Signed: 07/26/2024 10:48:54 AM

Document Has Been Signed on 07/26/2024 10:48 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:AMY NARASKY ARFFACILITY NUMBER:
361800427
ADMINISTRATOR/
DIRECTOR:		NARASKY, AMYFACILITY TYPE:
735
ADDRESS:13775 KIOWA ROADTELEPHONE:
(760) 912-4921
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 2CENSUS: 2DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Administrator Amy NaraskyTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analysts (LPAs) Sarina Ramirez and Mary Rico conducted an unannounced required annual inspection to the facility. LPAs met with Administrator Amy Narasky and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), level 2. The facility is an Inland Regional Center (IRC) certified vendor with a license capacity of (2) and a current census of (2). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant & Operation: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Facility's backyard is enclosed and gated. Indoor and outdoor activity areas are sufficient for clients in care. Client activities include community outings and day program participation. The facility has sufficient lighting and is maintained at a comfortable temperature. Client bathrooms were operating in sanitary conditions. The hot water temperature measured at 107 degrees F. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating fire alarms, laundry equipment and telephone service. The facility has sufficient linen and personal hygiene items for clients in care. Facility has firearms and ammunition locked separately in the garage inaccessible to clients in care. The facility has posted in a common area disaster evacuation plan, emergency telephone numbers, and personal rights poster.


Food Service: The facility has sufficient non-perishable and perishable food supply for clients in care. Sharps and chemicals were kept locked in kitchen area.
**** Continuation on LIC 809 – C****
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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: AMY NARASKY ARF
FACILITY NUMBER: 361800427
VISIT DATE: 07/26/2024
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Care & Supervision: Facility has 24 hour care staff. Staff working have criminal record clearances.

Record Review: Review of (2) Client files were observed to be complete. Review of (4) staff files were observed to be complete.

Medical Related Services: Clients in care are not on medication.

Based on observations and record review, no deficiencies were cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where the Licensing reports were discussed and copies of the reports were provided to Administrator Amy Narasky
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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