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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530068
Report Date: 01/31/2024
Date Signed: 01/31/2024 11:19:21 AM


Document Has Been Signed on 01/31/2024 11:19 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: 4DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Elodia Horwedel (Nora)- StaffTIME COMPLETED:
11:28 AM
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On 01/31/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Elodia Horwedel (Nora) and introduced self and stated purpose of the visit. LPA was informed that there are 4 clients at home getting ready to have breakfast.

The facility has 4 bedrooms, 3 bathrooms, kitchen, pantry room, dining area, living room, family room, laundry, attached garage and backyard with 2 sheds. LPA completed a walk through of facility, review of records, 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 73 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 107 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, facility license and CCL complaint poster were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to clients. There was a designated storage space for client/staff files. Medications was observed locked and inaccessible to clients. There is no firearms, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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: PIFER GROUP HOME II
FACILITY NUMBER: 365530068
VISIT DATE: 01/31/2024
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Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard and 2 sheds used for storage. All outdoor pathways were free of obstructions.

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

Record Review: LPA reviewed administrator and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed two client files for admission agreements, updated physician reports, and needs and services plans. P & I funds were counted at random and matched with the ledger. LPA observed missing signatures for representatives (staff & clients) on P&I records. Technical violation issued. Medication was audited along with MARS. LPA observed staff initial for client's 8PM medication during the AM medication dispensing. Technical violation issued. LPA reviewed facility's file for fire drills, infection control plan, and emergency disaster plan. LPA observed that the Infection Control Plan has no record of signature and date verifying that it has been reviewed. Technical violation issued. LPA observed the Emergency Disaster Plan not reviewed since 09/27/22. Technical violation issued.

No deficiencies but technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV were discussed and copies were provided to staff, Elodia Horwedel (Nora).

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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