360907488-1-22-2024-56-AS-JPRO-CZQU83-20240122142051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360907488
Report Date: 01/22/2024
Date Signed: 01/22/2024 02:21:02 PM

Document Has Been Signed on 01/22/2024 02:21 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	REALM VILLAGE II		FACILITY NUMBER:	360907488
ADMINISTRATOR:	MACALINO, ARLENE E.		FACILITY TYPE:	740
ADDRESS:	1295 AGATE STREET		TELEPHONE:	(909) 794-2800
CITY:	MENTONE	STATE: CA	ZIP CODE:	92359
CAPACITY:	10	CENSUS: 5	DATE:	01/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Arlene Macalino, Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Administrator Arlene Macalino. LPA explained the nature of today's visit. LPA accompanied with MS Macalino, conducted a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. There are no pools or other bodies of water located on the premises. There are no ammunition or firearms kept in the home. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at 115 degrees Fahrenheit in all resident bathrooms. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were tested and found to be in working order. Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods. Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: REALM VILLAGE II	FACILITY NUMBER: 360907488
	VISIT DATE: 01/22/2024

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Record Review: LPA requested and reviewed (5) resident and (1) staff files. LPA reviewed staff files for current CPR/1st aide certificates, TB results, and required training's. LPA reviewed client files for admissions agreement, physician report, and IPP

Administration: LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation.

Medical Related Services: Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions.

No deficiencies cited. An exit interview was conducted where this report was provided and discussed with MS Macalino

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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