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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412371
Report Date: 09/13/2023
Date Signed: 09/15/2023 10:30:09 AM

Document Has Been Signed on 09/15/2023 10:30 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:BRIDGET BARCUS ARFFACILITY NUMBER:
366412371
ADMINISTRATOR:BARCUS, BRIDGETFACILITY TYPE:
735
ADDRESS:15540 CHOLE RDTELEPHONE:
(760) 242-4230
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 4DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Bridget Barcus- AdministratorTIME COMPLETED:
03:25 PM
NARRATIVE
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On 09/13/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Bridget Barcus, introduced self and stated purpose of the visit.

The facility has 3 bedrooms, 2 bathrooms, kitchen, dining room, living room, family room, play room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility and review of records and P&I.

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 of 78 degrees fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA observed missing chairs for each client in their bedrooms. Deficiency issued. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 111.3 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. LPA observed the emergency disaster plan without a date. Technical violation issued. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to clients. Clients files with P&I included were observed not locked and made accessible to clients. Deficiency issued. Staff files were observed locked and inaccessible to clients. The facility had emergency kits, emergency food and water. LPA observed that the facility did not have a stock of hygiene products for clients. Deficiency issued. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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 5
Document Has Been Signed on 09/15/2023 10:30 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 09/13/2023 at 02:32 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: BRIDGET BARCUS ARF
FACILITY NUMBER: 366412371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in providing a chair for each client in their bedroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Admininstrator stated that she will purchase a chair for each client and place it in their bedroom. Administrator stated that she will submit a picture of chairs and receipt and send to LPA via email by POC due date.
Type B
Section Cited
CCR
85088(c)(5)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the administrator did not comply with the section cited above in providing a stock of hygiene products available for clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Administrator stated that she will provide and maintain a stock of hygiene products for clients. Administrator stated that she will submit a picture and receipt of hygiene products to LPA via email by POC due 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/15/2023 10:30 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 09/13/2023 at 02:32 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: BRIDGET BARCUS ARF
FACILITY NUMBER: 366412371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(j)
Safeguards for Cash Resources, Personal Property and Valuables
(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in locking the client's P&I monetary funds which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Administrator locked client's P&I monetary funds immediately. Administrator stated that she will provide an all staff training on regulation CCR 80026(j) and submit proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in maintaining complete personnel records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Administrator stated that she will submit the health screening for (S2) and first aid/cpr certification for (S1) to LPA by POC due date via email.
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: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


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: BRIDGET BARCUS ARF
FACILITY NUMBER: 366412371
VISIT DATE: 09/13/2023
NARRATIVE
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

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

Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed the health screening for (S2) missing and there a missing first aid/cpr certification for (S1). Deficiency issued. The facility last conducted a fire and earthquake drill on 09/02/23. P& I was audited and matched with record.

Deficiencies and a technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and LIC9102TV were discussed and copies were provided to the Administrator, Bridget Barcus

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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