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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002440
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:38:34 PM

Document Has Been Signed on 03/10/2022 02:38 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ALPINE BFACILITY NUMBER:
306002440
ADMINISTRATOR:BAHA, KHADIJA (HEIDI)FACILITY TYPE:
740
ADDRESS:24606 SATURNATELEPHONE:
(949) 380-3010
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Administrator Fahmi "John" MahfuzhiTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Fahmi "John" Mahfuzhi and stated the purpose of this visit.

This facility is a single level structure and licensed for six non-ambulatory and with hospice waiver for four. For this visit, there were three residents under hospice care. .

About 12:57 PM , LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed six residents in care and two staff members on the floor. There were two shared and two private rooms. Rooms were provided with furniture in good repair, clean linens, and adequate storage space. Smoke and carbon monoxide detectors were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid-floor mats. Hot water was measured at 120 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were in locked cabinets. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Side exit doors were self closing and self latching. Facility had a pool enclosed by steel fence inaccessible to residents in care. LPA Marin discussed the COVID 19 mitigation of the facility.

LPA Marin discussed the Assembly Bill (AB) 665. It requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device for use of the residents in care.

LPA Marin also directed AD Mahfuzhi to send all incident reports to CCLASCPOrangeCountyRO@dss.ca.gov

For this visit, no citation was issued on areas observed.

LPA Marin conducted an exit interview with AD Mahfuzhi, and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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