<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402621
Report Date: 05/10/2023
Date Signed: 05/10/2023 12:15:07 PM

Document Has Been Signed on 05/10/2023 12:15 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:NOBBS FAMILY HOME ARF IIIFACILITY NUMBER:
366402621
ADMINISTRATOR:JUDELSON C. ENRIQUEZFACILITY TYPE:
735
ADDRESS:20008 OUTER HWY 18TELEPHONE:
(760) 552-9176
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Richard Nobbs-AdministratorTIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/10/23 at 08:35 AM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted by Administrator, Richard Nobbs. LPA observed that there is currently 3 residents in the home and 1 resident out with the Licensee. LPA toured the facility inside and outside with the Administrator.

The facility has 4 bedrooms, 2 bathrooms, a kitchen, dining area, living room, family room, garage and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following:
Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 69 degrees F temperature. LPA inspected residents bedrooms; they are equipped with required furniture per regulations. An adequate supply of linens stored in the bathroom cabinet. LPA inspected residents bathroom; bathroom was clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet which tested at 114.3 degrees farenheit. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. LPA observed that the disaster plan poster, LIC610D was last reviewed on 02/03/2022. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for residents/staff files, first aid kit and medication. Per the Administrator, there are no firearms or ammunition. There is one gated swimming pool meeting regulations. The facility has a telephone with a landline that rings on the sender's end but not in the receiving side does not ring. LPA observed that the phone is not ringing when calling. Administrator stated that there is an issue with the telephone. Deficiency issued.
Yards/Outside:
One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard and two sheds that are used for the Administrator's personal use. All outdoor pathways were free of obstructions.
Nedra Brown
Michelle Echeverria
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 05/10/2023 12:15 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/10/2023 at 11:21 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: NOBBS FAMILY HOME ARF III
FACILITY NUMBER: 366402621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80073(a)
Telephones
(a) All facilities shall have telephone service on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in 4 out of 4 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
The Administrator stated that he will get the telephone fixed and submit proof of correction 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
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: NOBBS FAMILY HOME ARF III
FACILITY NUMBER: 366402621
VISIT DATE: 05/10/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry fully stocked and up to date. Facility has a variety of food available. Menu plan is posted on the kitchen's refrigerator. Dishes, cups, and utensils were stored properly. Emergency food and water were observed by the garage.

Record Review: LPA reviewed the residents files along with the staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

One deficiency was cited during this visit. One technical violation was issued. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and appeal rights were discussed and copies were provided to the Administrator, Richard Nobbs.

SUPERVISOR'S NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4