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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530006
Report Date: 10/09/2023
Date Signed: 10/09/2023 02:50:29 PM

Document Has Been Signed on 10/09/2023 02:50 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: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: 4DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Brianna Casteel- StaffTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/09/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Brianna Casteel introduced self and stated purpose of the visit.

The facility has 5 bedrooms, 3 bathrooms, kitchen, dining, living room, laundry room, play room, attached garage, and backyard with swimming pool and 2 sheds. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility, review of records, and P&I audit.

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 71 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 106.5 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarm, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, house rules and emergency disaster plan were posted in a common area. LPA observed that the Emergency Disaster Plan is outdated and not reviewed since 10/03/20. Deficiency issued. LPA observed that cleaning supplies, toxins, and medications were kept locked and inaccessible to clients. Clients/Staff files and P&I were observed locked and made inaccessible. The facility had emergency kits and emergency water. LPA observed a telephone, yet no active land line. Deficiency issued. There are no firearms, ammunition or bodies of water.

Yards/Outside: LPA observed one shaded patio, locked and inaccessible swimming pool, 2 storage 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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: KATHLEEN SACHS GUEST HOME
FACILITY NUMBER: 365530006
VISIT DATE: 10/09/2023
NARRATIVE
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Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Dishes, cups, and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed clients file for admission agreements, updated physician reports, and needs and services plans. LPA found discrepancies on client records: (C1) LIC602 does not a TB result and P&I counted does not match, no updated notes found for (C1) and (C2). Deficiency issued. LPA also reviewed 2 staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found discrepancies on personnel records: no current administrator certificate, 2012 TB LIC503 for administrator, expired first aid/CPR for (S1) and no TB result for (S2). Deficiency issued. LPA also found (S1) and (S2) have background clearance yet not associated to the facility. Deficiency with civil penalty issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and copies were provided to Staff Brianna Casteel.

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

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/09/2023 02:50 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/09/2023 at 01:53 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: KATHLEEN SACHS GUEST HOME
FACILITY NUMBER: 365530006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in requesting a transfer of criminal record clearance for (S1) and (S2) through Guardian which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2023
Plan of Correction
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Administrator stated that she will submit a request for transfer of criminal record clearance for (S1) and (S2) and submit proof to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/09/2023 02:50 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/09/2023 at 01:53 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: KATHLEEN SACHS GUEST HOME
FACILITY NUMBER: 365530006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
80073(a)
Telephones
(a) All facilities shall have telephone service on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the administrator did not comply with the section cited above in providing a functioning and active land line with telephone which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Administrator stated that she will activate a land line for telephone usage in the facility and provide proof of invoice and telephone # to LPA via email by POC due date.
Request Denied
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in maintaining complete and updated personnel records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will complete, update and provide a current administrator certificate, TB LIC503 for administrator, first aid/CPR for (S1) TB result for (S2) to LPA via email by POC due date.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/09/2023 02:50 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/09/2023 at 01:53 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: KATHLEEN SACHS GUEST HOME
FACILITY NUMBER: 365530006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in maintaining complete and updated client records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will complete, obtain, maintain and update (C1) LIC602 TB result and P&I log, and notes for (C1) and (C2). Administrator stated that she will submit proof to LPA via email by POC due date.
Request Denied
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in reviewing and updating annually the emergency disaster plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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Administrator stated that she will review and update the emergency disaster plan and submit proof to LPA via email by POC due date.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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