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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530143
Report Date: 11/08/2024
Date Signed: 11/08/2024 04:45:07 PM

Document Has Been Signed on 11/08/2024 04:45 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:BRIAN SCHWICHTENBERG ARFFACILITY NUMBER:
365530143
ADMINISTRATOR/
DIRECTOR:		SCHWICHTENBERG, BRIANFACILITY TYPE:
735
ADDRESS:18930 BEAR VALLEY ROADTELEPHONE:
(951) 295-6430
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 4DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Brian SchwichtenbergTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analysts (LPAs) Magda Malcore and Becky Mann made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Licensee Brian Schwichtenberg, granted entry into the facility, and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (4). The facility was recently certified through Inland Regional Center (IRC) . LPAs conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. Outdoor activity space is shaded and enclosed with a latching gate. The facility is equipped with smoke & carbon monoxide alarms, fully charged fire extinguisher, laundry equipment, and telephone service. The facility has a sufficient supply of bed linen, towels, and hygiene products for clients in care. Four (4) client bedrooms were equipped with beds, bed linen, nightstands, chairs, and lighting. Client bathroom was operating in a safe condition. The hot water in client bathroom tested at 105.8 degrees F. Sharps, disinfectants and cleaning supplies were stored in a locked cabinet. The facility has 24 hour/7 days a week care staff. The facility has posted: Community Care Licensing complaint poster, emergency disaster plan with telephone numbers, client personal rights, house rules, weekly menu and facility license. The facility maintains a current liability, surety bond, and client registry on file.

Food Service: The facility’s kitchen area was maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care.

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

Personnel/Client Records: Three (3) staff files were reviewed for employment history, CPR/first aid training, health screenings, and criminal record clearances. Staff #1 did not have a health screening with tuberculosis results on file for LPA review. Four (4) client files were reviewed for admission agreements, medical assessments, needs and service plans, and P&I records.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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: BRIAN SCHWICHTENBERG ARF
FACILITY NUMBER: 365530143
VISIT DATE: 11/08/2024
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During today's visit, deficiencies were cited and technical advisories were issued per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where report (LIC809/LIC809-C/LIC809-D/LIC9102) were discussed. Copies with appeal rights were provided to the Licensee at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2024 04:45 PM - It Cannot Be Edited


Created By: Magda Malcore On 11/08/2024 at 04:00 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: BRIAN SCHWICHTENBERG ARF
FACILITY NUMBER: 365530143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80066(a)(10)
(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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by staff #1 (S1) did not have a current health screening with Tuberculosis results on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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The Licensee/Administrator shall submit a health screening for staff #1 by plan of correction 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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