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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530006
Report Date: 10/21/2024
Date Signed: 10/21/2024 12:59:52 PM

Document Has Been Signed on 10/21/2024 12:59 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/
DIRECTOR:		SACHS, KATHLEENFACILITY TYPE:
735
ADDRESS:16500 KALO RD.TELEPHONE:
(951) 452-7257
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 4DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Kathleen Sachs- AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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 Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Kathleen Sachs introduced self and stated purpose of the visit.

The facility has 2 client bedrooms, 1 client bathroom, 3 staff bedrooms, 2 staff bathrooms, kitchen, dining area, living room, laundry room, play room, attached garage, 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 and medication 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 69 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 105.6 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarm, charged fire extinguishers, and first aid kit. Posters such as; the personal rights, CCL complaint poster, house rules and emergency disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to clients. Clients/Staff files and P&I were observed locked and made inaccessible. The facility had emergency kits and emergency water. There are no firearms and ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

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 left and 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: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KATHLEEN SACHS GUEST HOME
FACILITY NUMBER: 365530006
VISIT DATE: 10/21/2024
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Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Facility has a variety of food available. 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 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P& I and medication were audited and matched with record. The facility last conducted an earthquake and fire drill on 9/30/24. The Emergency Disaster Plan was last reviewed on 3/9/24.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed and copies were provided to Administrator, Kathleen Sachs.

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

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC809 (FAS) - (06/04)
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