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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800234
Report Date: 08/22/2024
Date Signed: 08/22/2024 06:04:43 PM


Document Has Been Signed on 08/22/2024 06:04 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:EAGLE GLEN CARE HOME INCFACILITY NUMBER:
331800234
ADMINISTRATOR:RESTITUTO L. CALILUNGFACILITY TYPE:
740
ADDRESS:1697 HONORS CIRCLETELEPHONE:
(714) 906-6046
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY:6CENSUS: 5DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Adminstrator Restituto CalilungTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Adminstrator Restituto Calilung, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (5) residents in care and a hospice waiver for (6). LPA Ramirez conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has a swimming pool gated and locked inaccessible to residents in care. Outdoor shaded area is sufficient for resident activities and is enclosed with self-latching gate. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating carbon monoxide alarms and telephone service. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary conditions. The hot water temperature in thee (3) resident bathrooms measured 105,106, and 108 degrees F. Five (5) resident’s bedrooms had beds, bed linen, chairs, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, complaint poster, Ombudsman poster, facility license, disaster evacuation plan, emergency telephone numbers, food menu, and activities.

Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps were kept unlocked and accessible to residents in care, technical violation cited.

Continuation on LIC – 809C:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina RamirezTELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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: EAGLE GLEN CARE HOME INC
FACILITY NUMBER: 331800234
VISIT DATE: 08/22/2024
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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet, Technical Assistance issued. The facility has sufficient first aid supplies.

Record Review: The Administrator's certification is current. The facility’s last fire drill was conducted on 4/2/24, and last earthquake drill was conducted on 7/2/24. Three (3) Staff files reviewed were observed to be complete. Three (3) Resident files reviewed were observed to be complete.

Based on observations and record review, technical violation and technical assistance will be issued per Title 22, of The California Code of Regulations.

An exit interview was conducted where the Licensing reports were discussed and copies with appeal rights were provided to Adminstrator Restituto Calilung.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina RamirezTELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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