361881204-3-15-2023-56-AS-ACON-CPXTXT-20230315150740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881204
Report Date: 03/15/2023
Date Signed: 03/15/2023 03:07:47 PM

Document Has Been Signed on 03/15/2023 03:07 PM - 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:	PITACHE RESIDENTIAL		FACILITY NUMBER:	361881204
ADMINISTRATOR:	WILLIAMS, NATALIE		FACILITY TYPE:	735
ADDRESS:	18025 PITACHE ST.		TELEPHONE:	(909) 671-2812
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 4		CENSUS: 1	DATE:	03/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jennifer Vargas, DSP		TIME COMPLETED:	03:05 PM

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Licensing Program Analyst, Amber Coleman (LPA Coleman) and Michelle Echeverria, (LPA Echeverria) arrived at the Pitache Residential Facility to conduct an Annual Inspection. LPAs knocked on the door and were greeted by staff member, Jennifer Vargas. LPA’s introduced self and stated the purpose of the visit. LPA’s were invited inside of the facility, had temperature taken and signed in. LPA’s were provided a space to set up and then began a walkthrough of the physical plant. LPA’s were informed the facility census is 1. There are currently 3 residents in care, 2 of the residents were at their adult day programs at the time of the visit. Administrator was not present upon arrival, but arrived to facility later during LPA visit.

LPA’s visit consisted of a walk through, staff interviews, review of staff and resident files. Resident rooms all included adequate furniture, a bed, night stand, lighting, a television, and storage. Each bathroom included adequate amount of paper and hand hygiene supplies. Showers equipped with grab bars and non-slip grip products.

Extra linens, chemicals are kept in a secure hallway closet. Additional supplies are also kept in sliding door closet. The facility conducts disaster drills every three months. Last fire and earthquake drill conducted 12/20/23. Fire/Carbon Monoxide alarms tested and observed functional. Facility phone called and found operational.

Continued on LIC 809D

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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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Document Has Been Signed on 03/15/2023 03:07 PM - It Cannot Be Edited

Created By: Amber Coleman On 03/15/2023 at 02:51 PM

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: PITACHE RESIDENTIAL	FACILITY NUMBER: 361881204
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, of the backyard shed on the left side the licensee did not comply with the section cited above by not making items such as gas propane tanks, yard tools and concrete inaccessible to resident which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	Administrator and LIcensee agree to have the selected items removed from the shed and made inaccesible to the residents in care. Administrator and Licensee agree to submit proof of the removal by submitting photos and reporting where they put the problems items to render them inaccessible. Adminstrator agrees to complete these tasks by the end of the dat 3/16/23/

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Nedra Brown

LICENSING EVALUATOR NAME:

Amber Coleman

LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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: PITACHE RESIDENTIAL	FACILITY NUMBER: 361881204
	VISIT DATE: 03/15/2023

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At approximately 1:15pm LPA’s walked through the backyard of the facility. The backyard is divided into two halves. The half at the back of the yard includes 2 sheds and 2 inoperable cars. The shed on the left hand side did not have a door attached. Inside the shed, LPA observed 2 propane tanks on the ground, 3 bags of concrete as well as what appeared to be a water pressure machine and a wooden ladder leaned up against other items. Staff reported, that resident’s do utilize that half of the yard and do not use the area. LPA advised staff that if the shed cannot be secured, the items will need to be secured and rendered inaccessible to residents.

The kitchen included adequate amounts of perishable and non-perishable food for the census of residents in care. Staff showed LPA’s a secure drawer were sharp items are kept. LPA also observed a secure file cabinet next to the refrigerator where the resident files are kept. File cabinet was along side about secure cabinet where medications are centrally stored.

A review of staff and resident files revealed adequate completed documents which met the regulations.

A deficiency will be issued to address the aforementioned backyard. Please see LIC809D. An exit interview was conducted, this report was discussed and provided to Administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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