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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402978
Report Date: 12/26/2024
Date Signed: 12/26/2024 04:30:23 PM

Document Has Been Signed on 12/26/2024 04:30 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PIFER FAMILY HOMEFACILITY NUMBER:
366402978
ADMINISTRATOR/
DIRECTOR:		PIFER, LAURAFACILITY TYPE:
735
ADDRESS:19956 TINNE ROADTELEPHONE:
(760) 242-7832
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Bridget Barcus, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Becky Mann made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection. LPA met with Bridget Barcus, Administrator. The facility is a (4) bedroom, (3), bathroom home with a kitchen/dining area, living room, attach garage and unattached garage. The facility is an Adult Residential Facility (ARF). Licensed capacity is (6) current census (4). LPA conducted an overall inspection of the facility, which included, but was not limited to the following:

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. LPA inspected client bedrooms; they are equipped with required furniture such as: beds, mattresses, nightstands, storage space, and sufficient lighting. Client bathrooms were clean and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested between 109 degrees and 113 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Nedra BrownTELEPHONE: (951) 202-5776
Becky MannTELEPHONE: 951-248-0306
DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PIFER FAMILY HOME
FACILITY NUMBER: 366402978
VISIT DATE: 12/26/2024
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

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

Record Review: LPA reviewed (4) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (2) client medications. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Bridget Barcus, Administrator.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky MannTELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC809 (FAS) - (06/04)
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