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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530006
Report Date: 05/23/2022
Date Signed: 05/23/2022 11:29:52 AM

Document Has Been Signed on 05/23/2022 11:29 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:KATHLEEN SACHS GUEST HOMEFACILITY NUMBER:
365530006
ADMINISTRATOR:SACHS, KATHLEENFACILITY TYPE:
735
ADDRESS:16500 KALO RD.TELEPHONE:
(951) 452-7257
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 0DATE:
05/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Kathleen SachsTIME COMPLETED:
11:39 AM
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Licensing Program Analyst (LPA) Ryan Gardner conducted an announced pre-licensing inspection during today’s visit. LPA Gardner met with Licensee and Administrator, Kathleen Sachs.

This facility is currently licensed as Kathleen Sachs Guest Home, license number 365530006. Today's pre-licensing inspection is for a change of location application with four (4) clients in care. The fire clearance was approved on 5/3/2022 for four (4) ambulatory clients.

This facility is a change of location from Kathleen Sachs Home, license number 366427609. The clients and some of the items needed in the facility will be moved to the new facility once the new facility is fully approved due to the items being currently used by the clients. The Licensee was notified that a post licensing visit will be required to verify the items moved from the old facility to the new facility.

The facility is a five (5) bedroom, three (3) bath home. There are two (2) client bedrooms, two (2) staff bedrooms, one (1) spare bedroom that will be used as a COVID-19 quarantine room, a kitchen/dining area, a living room, game room, laundry room, backyard, a pool with a locked fence surrounding the pool, and attached garage. LPA Gardner and Licensee toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms will have the required bedding and furniture once it is moved over from the other facility, such as, clean mattresses/linen, night stands, dressers, chairs, and lighting.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: KATHLEEN SACHS GUEST HOME
FACILITY NUMBER: 365530006
VISIT DATE: 05/23/2022
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Client Bathrooms: The bathroom appliances were operating in safe and sanitary conditions. The water temperature was measured by LPA Gardner. The thermometer read at 118 degrees F.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter tops were free of debris and in good repair.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.

Laundry Room: The laundry area is secured by a door from the hallway. The laundry door is locked to ensure knives/sharps, cleaning supplies/toxins, and hygiene items are not accessible to the clients.

Backyard: There is pool with locked fence surrounding the pool. There is a covered area with seating. All passageways were free from obstruction.

LPA Gardner and Licensee observed a locked staff room that will serve as centralized storage for client and staff files. The facility has a supply personal protective equipment (PPE) that is centrally stored in the garage.


There were two (2) charged fire extinguishers in the facility. There were operating smoke detectors and carbon monoxide alarms observed at the time of visit. LPA Gardner observed required postings including the visitation polices, emergency/disaster plans, and personal rights. The facility was equipped with a complete first aid kit and manual. The facility will have a working telephone for client use once it is moved from the old facility.

LPA Gardner observed that the physical plant is clean, in good repair, and appears to be hazard-free during today’s visit. LPA Gardner has determined that the facility is meeting operational requirements for the clients.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: KATHLEEN SACHS GUEST HOME
FACILITY NUMBER: 365530006
VISIT DATE: 05/23/2022
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The pre-licensing inspection is complete, and this facility has no deficiencies. The Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed, and a copy was provided to Kathleen Sachs.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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