365530068-12-9-2024-56-AS-MMAE-DBSRKF-20241209120529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530068
Report Date: 12/09/2024
Date Signed: 12/09/2024 12:05:46 PM

Document Has Been Signed on 12/09/2024 12:05 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:	PIFER GROUP HOME II		FACILITY NUMBER:	365530068
ADMINISTRATOR/ DIRECTOR:	SACHS, KATHLEEN		FACILITY TYPE:	735
ADDRESS:	13329 WACO LN		TELEPHONE:	(760) 240-4182
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY: 4		CENSUS: 3	DATE:	12/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Lorria Shatto		TIME VISIT/ INSPECTION COMPLETED:	12:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA was granted entry into the facility by Caregiver, Lorria Shatto, and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (3). LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility maintains an infection control plan and emergency disaster plan on file. The facility's staff schedule reflects 24 hour, 7 days a week care staff coverage. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility's has two outdoor sheds which were observed locked. The facility has a living room and family room which are sufficient for client activities. The facility is equipped with operating smoke/carbon monoxide alarms, laundry equipment, and telephone service. The facility has posted in a common area: Facility license, house rules, emergency telephone numbers and evacuation sketch. The facility has a sufficient supply of bed linen, towels, and hygiene products for clients in care. Three (3) client bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space and lighting. Client bathroom equipment was operating in safe conditions. The hot water in client bathroom tested at 113 degrees F. Disinfectants, cleaning supplies, sharps were kept in a locked room. No night lights were observed in the hallway leading to client bathroom. Deficiency cited.

Food Service: The facility’s two (2) dining areas and kitchen area were maintained clean. The facility has sufficient supply of cups, plates, and utensils for clients. The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s freezer temperature is maintained at zero degrees. The facility has a weekly menu available for review.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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: 12/09/2024

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Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked container and room.

Personnel/Client Records: Staff records reviewed had health screenings, criminal record clearances, and first aid/CPR training certifications. Client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs (P&I). Review of Client #1's (C1) P&I actual funds compared to last ledger entry/ending balance on 12/01/24, reveals a cash overage. Review of Client #2's (C2) P&I funds on hand compared to the last ledger entry/ending balance on 12/04/24, reveals a cash shortage. Deficiency cited.

During today's visit, deficiencies were cited and technical advisories were issued in accordance with Title 22 of the California Code of Regulations.

An exit interview was conducted were reports LIC809, LIC809-C, LIC809-D, LIC9102 and plans of corrections were discussed. Copies of the reports with appeal rights were provided to Caregiver, Shatto at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/09/2024 12:05 PM - It Cannot Be Edited

Created By: Magda Malcore On 12/09/2024 at 11:31 AM

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: PIFER GROUP HOME II	FACILITY NUMBER: 365530068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80026(h)

80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by not maintaining an accurate record of Client #1 and Client #2's P&I funds and ledgers; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit a statement of understanding of regulation cited by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Karen Clemons

LICENSING EVALUATOR NAME:

Magda Malcore

LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 12/09/2024 12:05 PM - It Cannot Be Edited

Created By: Magda Malcore On 12/09/2024 at 11:42 AM

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: PIFER GROUP HOME II	FACILITY NUMBER: 365530068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(e)(2)

Fixtures, Furniture, Equipment, and Supplies

(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not maintaining night lights in the hallway leading to client bathroom; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the licensing agency proof of correction by plan of correction date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Karen Clemons

LICENSING EVALUATOR NAME:

Magda Malcore

LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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