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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004524
Report Date:
06/03/2024
Date Signed:
06/03/2024 05:32:51 PM
Document Has Been Signed on
06/03/2024 05:32 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 B II CARE
FACILITY NUMBER:
306004524
ADMINISTRATOR:
KAHDIJA"HEIDI"BAHA
FACILITY TYPE:
740
ADDRESS:
26352 PAPAGAYO DRIVE
TELEPHONE:
(949) 454-8349
CITY:
MISSION VIEJO
STATE:
CA
ZIP CODE:
92691
CAPACITY:
6
CENSUS:
DATE:
06/03/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:45 PM
MET WITH:
Heidi Baha, Administrator
TIME COMPLETED:
05:00 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 conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself. Facility administrator Heidi Baha was notified by telephone and arrived later to assist with the visit..
During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one-story home. Facility has one shared room and four private rooms plus one staff room, as well as one shared bathroom and half bathrooms in addition to the common living areas. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently five residents admitted to the facility with two residents receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be above the required temperature. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted, however the current form is not in use. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Combined smoke and carbon monoxide detectors tested operational. Fire extinguishers present are observed to be fully charged with up-to-date maintenance. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed five resident files and four staff files.
Based on the observations made during today’s inspection, one type A deficiency and six type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Two Technical Violation and one Technical Assistance Advisory Note were provided to the licensee based on consultations provided during the visit. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISOR'S NAME:
Sheila Santos
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
06/03/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/03/2024
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
9
Document Has Been Signed on
06/03/2024 05:32 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ALPINE B II CARE
FACILITY NUMBER:
306004524
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/03/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above as the water was measured at approximately 130F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/04/2024
Plan of Correction
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2
3
4
Licensee immediately adjusted the furnace during the visit and will provide LPA with documentation of a water measured within the 105F to 120F before the plan of corrections due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
06/03/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/03/2024
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
06/03/2024 05:32 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ALPINE B II CARE
FACILITY NUMBER:
306004524
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/03/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above after water measured above 130F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2024
Plan of Correction
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2
3
4
Licensee will ensure the water is no longer delivered above 125F or put signs into place before the plan of corrections due date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in as multiple caregivers have not received an update of their CPR training after it expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2024
Plan of Correction
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3
4
Licensee will ensure that at least one staff member with CPR training is present per shift and present documentation thereof before the plan of corrections due date.
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
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
06/03/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/03/2024
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
06/03/2024 05:32 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ALPINE B II CARE
FACILITY NUMBER:
306004524
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/03/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as two out of four staff members did not show as association to the facility in Guardian which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2024
Plan of Correction
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2
3
4
As the required documentation was present, LPA was able to associate one of the two caregivers during the present visit. Licensee will request and obtain transfer of the current clearance for the fourth caregiver before the plan of corrections due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on staff records reviewed, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2024
Plan of Correction
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3
4
Licensee will ensure annual training is held and documented before the plan of corrections due date.
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
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
06/03/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/03/2024
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
06/03/2024 05:32 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ALPINE B II CARE
FACILITY NUMBER:
306004524
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/03/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff records reviewed, the licensee did not comply with the section cited above as no recurring annual training was documented on the topic which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2024
Plan of Correction
1
2
3
4
Licensee will provide updated training on its disaster and emergency plan before the plan of corrections due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and records reviewed, the licensee did not comply with the section cited above as no drills have been conducted recently which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2024
Plan of Correction
1
2
3
4
Licensee will schedule and organize fire and emergency drills for the present and upcoming quarters before the plan of corrections due date.
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
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
06/03/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/03/2024
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
06/03/2024 05:32 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ALPINE B II CARE
FACILITY NUMBER:
306004524
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/03/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(1)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on facility observation and records reviewed, the licensee did not comply with the section as one resident recently discharged from hospice still shows a bed equipped with two sets of half rails without a physician order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2024
Plan of Correction
1
2
3
4
Licensee is planning to contact the resident's primary care physician and obtain a prescription for half-rails for the resident in question before the plan of corrections due date.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on resident records reviewed during the visit, the licensee did not comply with the section cited above as one physician report for a resident diagnosed with dementia was last updated in June 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2024
Plan of Correction
1
2
3
4
Licensee has already requested an updated physician report and will make sure to obtain it from the resident's new primary care provider before the plan of corrections due date.
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
TELEPHONE:
(714) 334-2062
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
TELEPHONE:
(714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE:
06/03/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/03/2024
LIC809
(FAS) - (06/04)
Page:
6
of
9