<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530257
Report Date: 12/05/2024
Date Signed: 12/05/2024 11:02:09 AM

Document Has Been Signed on 12/05/2024 11:02 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:ALEGNA RESIDENTIALFACILITY NUMBER:
365530257
ADMINISTRATOR/
DIRECTOR:		CALHOUN, ANGELAFACILITY TYPE:
740
ADDRESS:19040 APPALOOSA RDTELEPHONE:
(760) 265-8567
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 0DATE:
12/05/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Angela CalhounTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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) Magda Malcore conducted an announced Pre-Licensing visit to the facility. LPA met with applicant Angela Calhoun and was granted entry into the facility. An application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB). Fire clearance was granted by the Apple Valley Fire District on 9/26/2024 for a total capacity of four (4) ambulatory.

The facility consist of 4 bedrooms, 2 1/2 bathrooms, family room, living room, dining room, staff office, and attached garage. LPA observed the following during the inspection:

Physical Plant: Indoor and outdoor passageways and inclines were free of obstruction. The facility has a swimming pool which was observed gated and locked. Outdoor activity area is shaded and enclosed with two (2) self-latching gates. The facility has an outdoor locked shed utilized to store gardening tools. The facility has sufficient lighting and is operating at a temperature of 75 degrees F. An adequate amount of space, supplies, games was observed for client activities. The facility has telephone service, smoke/carbon monoxide detectors (upstairs/downstairs), laundry equipment, (3) fully charged fire extinguishers and a covered fireplace. A locked closet was observed were cleaning supplies, disinfectants, and sharps were stored.

Bedrooms: Client bedrooms were equipped with a clean mattresses, mattress covers, chairs, nightstands, sufficient linen and lighting.

Bathrooms: Client bathrooms are clean and equipped with operating toilets, washbasins, showers. Hot water temperature measured at 118 degrees F.

Supplies: The facility has sufficient supply of linens, towels and hygiene products, and first-aid kit.

Food Service: The facility's kitchen and food preparation area were clean with an adequate number of dishes and utensils. Food storage cabinets are large enough for a seven (7) day supply of non-perishable foods. The refrigerator and freezer are clean and operating in good condition; there is enough storage for at least two (2) days of perishable foods.

Medications: A designated client medication closet was observed locked and secure.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 3
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: ALEGNA RESIDENTIAL
FACILITY NUMBER: 365530257
VISIT DATE: 12/05/2024
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
26
27
28
29
30
31
32
Records: Designated client and staff files will be kept in staff office.

Administration: Emergency exiting plan and telephone numbers, personal rights and were posted in a common area. The facility has documentation of an infection control plan and emergency disaster plan.

The Pre-licensing inspection and the Comp III orientation were completed during today's visit.



An exit interview was conducted where this report was discussed and a copy provided to the applicant at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3