366412343-2-20-2024-56-AS-ACON-D2MV7W-20240220151149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366412343
Report Date: 02/20/2024
Date Signed: 02/20/2024 03:11:59 PM

Document Has Been Signed on 02/20/2024 03:11 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	RL HOME CARE II		FACILITY NUMBER:	366412343
ADMINISTRATOR:	ROBERT LANDICHO		FACILITY TYPE:	735
ADDRESS:	1431 N. ASH AVE.		TELEPHONE:	(909) 421-1094
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	6	CENSUS: 2	DATE:	02/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Mark Munoz, Staff #1, Virgilio Maribao, Staff #2		TIME COMPLETED:	03:15 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, Amber Coleman, (LPA) arrived at the RL Home Care, Adult Residential Facility, unannounced to conduct an Annual Inspection. LPA rang the doorbell, then greeted by Care Provider Mark Munoz. LPA introduced self and stated purpose of the visit, then was granted entry. Care Provider, Virgilio Mariboa arrived later during the visit and contacted Administrator, Robert Landicho. LPA spoke with Administrator over the phone. Administrator agreed to meet with LPA at facility. LPA was accompanied by Care Providers, Mark and Virgilio on a walk through of the facility. LPA observed the following: The facility is comprised of five, (5) bedrooms, two, (2) bathrooms, Living Room, Kitchen, Dinning Room, Office Space, Den, attached garage and backyard. The facility is licensed for six, (6) ambulatory residents. This facility also maintains a partnership with Inland Regional Center, at Level 3. Care Providers report the current census is 2. Physical Plant: LPA observed the facility to be maintained at a comfortable temperature. Pathways throughout the facility were free of clutter and obstructions. There are 4 bedrooms for residents, 1 bedroom for facility staff who reside on facility grounds. Each resident room included a bed with appropriate linens, a night stand, storage space, seating, privacy and lighting. Each bathroom included adequate paper supplies, hand soap, handrails. non-slip grip materials and functional appliances. Dining and Living Rooms included various activities and adequate seating for residents and guests. Office Space was created in the Living Room; where facility, staff files, resident files and medications are securely maintained. LPA observed a fully charged fire extinguisher near the kitchen/dining area. Fire Extinguisher last inspected February 2023. The facility is also equipped with operable fire and carbon monoxide alarms. Administrator reports Fire/Disaster Drills are conducted monthly.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RL HOME CARE II	FACILITY NUMBER: 366412343
	VISIT DATE: 02/20/2024

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Food Service: The facility Kitchen included operable appliances, hand soap and paper supplies.
LPA observed sufficient amounts of dishware, silverware and cups for the amount of residents in care. Adequate amounts of non-perishable and perishable were observed in the kitchen pantry and 2 refrigerators. LPA observed condiments, bread, eggs, frozen meals, meats and a variety of beverages. LPA confirmed all sharp objects, chemicals and dangerous items were securely stored. Water temperature measured between 105 to 108 degrees Fahrenheit.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. One Staff Member resides on facility grounds and while additional staff work in shifts during the day to provide care.

Record Review: LPA reviewed resident files for Admission Agreements, updated Physician Reports, and Needs and Services Plans. Each Resident file was complete with required documentation. LPA reviewed staff files for First Aid/CPR certification, Criminal Record Clearance, Fingerprints, annual training, and health screenings. Each Staff file contained all required documentation.

Posters & Signs - LPA observed the following posters in prominent places throughout the facility: Resident Rights, Facility Sketch, Facility Menu, Activities Calendar, Facility License, Mandated Reporting, Long Term Care Ombudsman, Infection Control. and SEE/SAY Something.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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