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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002440
Report Date: 07/17/2023
Date Signed: 07/17/2023 01:48:42 PM

Document Has Been Signed on 07/17/2023 01:48 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
ORANGE & INLAND A/SC, 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: 1DATE:
07/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Khadija (Heidi) Baja, LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting a deficiency observed during the initial investigation visit regarding complaint 22-AS-20230712110106.

LPA accompanied by licensee toured the facility's physical plant. Two fire extinguishers are observed to be mounted on the walls of the common areas. Both maintenance tags observed show that the last maintenance was performed in October 2019, meaning the annual maintenance obligation has lapsed in October 2020, over two years before the present visit. A type B citation is being issued.

An exit interview was conducted and a copy of this report along with appeal rights were provided and left to facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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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Document Has Been Signed on 07/17/2023 01:48 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/17/2023 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALPINE B
FACILITY NUMBER: 306002440

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
87303(a)

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The California Code of Regulations Section 87303(a) on Maintenance and Operation states that: " The facility shall be (...) safe, (...) and in good repair at all times. Maintenance shall include provision of maintenance services(...)." This requirement is not met as evidenced by:
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Licensee is to schedule the required annual maintenance on both mounted fire extinguishers and provide documentation thereof to LPA before the Plan of Correction due date.
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Based on observation conducted, the two mounted fire extinguishers were observed to have expired maintenance tags dated October 2019. This poses a potential risk to the health, safety and/or personal rights of individuals in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023


LIC809 (FAS) - (06/04)
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