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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402978
Report Date: 12/28/2022
Date Signed: 12/28/2022 10:46:06 AM

Document Has Been Signed on 12/28/2022 10:46 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 FAMILY HOMEFACILITY NUMBER:
366402978
ADMINISTRATOR:PIFER, LAURAFACILITY TYPE:
735
ADDRESS:19956 TINNE ROADTELEPHONE:
(760) 242-7832
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Laura Pifer, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Pifer Family Home unannounced to conduct the annual inspection with a focus on infection control. LPA introduced self and stated purpose of the visit. LPA was greeted and invited inside facility. There are currently 4 residents in care, who were consuming breakfast at LPA arrival. Upon entry, LPA observed a COVID station in pathway to kitchen. Station included sign in sheets, thermometer, hand sanitizer and PPE made available to all who enter. As well as, COVID signage posted above station on cork board. Administrator introduced self as Laura Pifer and provided LPA space to work. At this time, there are no residents suspected or showing symptoms of COVID.

During today's visit, LPA walked through facility and made observations LPA Coleman interviewed Administrator pertaining to the facility's infection control measures and other health and safety concerns. LPA Coleman observed necessary signs posted in the facility, which were in accordance with the Department's guidelines. Administrator stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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 FAMILY HOME
FACILITY NUMBER: 366402978
VISIT DATE: 12/28/2022
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Fire extinguisher is fully charged, last purchase date of 8/18/22. Fire and Carbon Monoxide alarms tested and found operational. Last fire drill 12/10/22. Emergency food supply located in attached garage. Cleaning solutions observed in secure file cabinet in garage. Extra PPE and 1st aid kits observed in the pantry. Sharp objects observed secure in Administrator Office. Water temperature tested at 110 to 116 degrees Fahrenheit.

Administrator explained that she is still awaiting her Administrator Certification. LPA observed list of pending Administrators. New expiration date 9/23/2023 No: 6026360735. Personnel files reviewed; observed to be complete including all pertinent information.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC809 (FAS) - (06/04)
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