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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530068
Report Date: 12/02/2022
Date Signed: 12/02/2022 10:32:39 AM

Document Has Been Signed on 12/02/2022 10:32 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PIFER GROUP HOME IIFACILITY NUMBER:
365530068
ADMINISTRATOR:SACHS, KATHLEENFACILITY TYPE:
735
ADDRESS:13329 WACO LNTELEPHONE:
(760) 985-4175
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 0DATE:
12/02/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Elodia Horwedel- CaregiverTIME COMPLETED:
10:43 AM
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Licensing Program Analyst (LPA) Ryan Gardner conducted an announced visit to complete the facilities Pre-licensing inspection. LPA met with Caregiver Elodia Horwedel who is here today in place of Licensee Laura Pifer. The application is for an Adult Residential Facility for four (4) ambulatory clients. The fire clearance was approved on 10/24/2022.

The facility is a four (4) bedroom, two (2) bath home. There are two (2) client bedrooms, one (1) staff bedroom, one (1) staff office, a kitchen/dining area, two (2) living room areas, a locked laundry room, a backyard, and an attached garage. LPA Gardner and Caregiver toured the interior and exterior areas of the facility. The following areas were inspected:

Client Bedrooms: All bedrooms will have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Client Bathroom: The bathroom appliances were operating in safe and sanitary condition. The water temperature was measured by LPA, the thermometer read at 114 degrees F.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and countertop were free of debris and in good repair. The refrigerator was measured at 45 degrees F and the freezer was measured at 0 degrees F. The knives and sharps were safely locked and secured. The medication box was secured and locked.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the residents.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PIFER GROUP HOME II
FACILITY NUMBER: 365530068
VISIT DATE: 12/02/2022
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Laundry Room: The laundry room is near the entry to the garage. The chemicals and laundry soap were safely locked in this room.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available.

Backyard: There are no bodies of water in the backyard. There is a covered area with seating for the all the clients. All passageways were free from obstruction.

Fire extinguisher and Carbon monoxide: There were two (2) charged fire extinguishers in the facility. There were operating smoke detectors and carbon monoxide alarms observed.

Postings: LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, and personal rights.

First aid and working telephone: The facility was equipped with a complete first aid kit and manual. The facility has working telephone for client use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA has determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Caregiver Elodia Horwedel.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC809 (FAS) - (06/04)
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