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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002440
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:56:37 PM

Document Has Been Signed on 08/01/2023 03:56 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ALPINE BFACILITY NUMBER:
306002440
ADMINISTRATOR:MALACA, ROCHELFACILITY TYPE:
740
ADDRESS:24606 SATURNATELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 1DATE:
08/01/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rochele Malaca, Administrator
Kim Arnett, assistant administrator		TIME COMPLETED:
01:59 PM
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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 verifying the implementation of the corrections required by a type B deficiency cited on July 21, 2023. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit.

Wall-mounted fire extinguishers in the entrance hallway and in the kitchen are observed to have updated maintenance tags dated July 2023, replacing the previously outdated tags observed during the previous visit. As a result, the previous deficiency is cleared.

Another deficiency was however observed during the visit. Previous licensee Khadija "Heidi" Baha terminated maintenance service for the outdoor swimming pool. Water circulation was kept on, but water treatment appears to have lapsed as evidenced by green water and a significant presence of insect larvae in the water. Facility staff states that maintenance and water treatment will be performed on August 2, 2023.

A type B citation is issued per the deficiency observed.

Exit interview conducted. A copy of this report along with the corresponding Plan of Correction Clearance letter and appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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 08/01/2023 03:56 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 08/01/2023 at 03:23 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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
87303(a)

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The California Code of Regulations Section 87303(a) on Maintenance and Operation states that: "Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors." This requirement is not (...)
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Licensee to perform ongoing treatment and eradicate the mosquito infestation due to untreated swimming pool water. Proof of the conduction of necessary maintenance to be provided to LPA before the plan of correction due date.
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met as evidenced by: Based on interviews and observation conducted, no maintenance has been performed for the treatment of the pool's water resulting in the presence of insects. This constitutes a potential risk to the health, safety and personal rights of residents 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: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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