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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360907488
Report Date: 01/28/2022
Date Signed: 01/28/2022 01:36:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REALM VILLAGE IIFACILITY NUMBER:
360907488
ADMINISTRATOR:MACALINO, ARLENE E.FACILITY TYPE:
740
ADDRESS:1295 AGATE STREETTELEPHONE:
(909) 794-2800
CITY:MENTONESTATE: CAZIP CODE:
92359
CAPACITY:10CENSUS: 7DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Arlene MacalinoTIME COMPLETED:
01:39 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for an annual inspection. LPAs met with administrator Arlene Macalino.

LPA toured the facility inside and out. The facility has no bodies of water. The facility has charged fire extinguishers, smoke alarms, and carbon monoxide detectors. Cleaning supplies, medications, and sharps were kept in a safe and locked place. Medications were kept in a locked cabinet. LPA observed more two (2) days of perishable food items and seven (7) days of nonperishable food items. The resident bedrooms had the required furniture and sufficient lighting. Facility had a supply of additional linen and hygiene items.

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents any change in condition for staff and clients. LPA observed hand sanitizer throughout the facility and 30 day supply of PPE housed in the private residence behind the facility. All clients have at least a 30 day supply of medications.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to the Administrator at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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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