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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004524
Report Date: 05/27/2022
Date Signed: 05/27/2022 11:40:16 AM


Document Has Been Signed on 05/27/2022 11:40 AM - 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 B II CAREFACILITY NUMBER:
306004524
ADMINISTRATOR:KAHDIJA"HEIDI"BAHAFACILITY TYPE:
740
ADDRESS:26352 PAPAGAYO DRIVETELEPHONE:
(949) 454-8349
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Administrator Heidi BahaTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Heidi Baha 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 three. For this visit, there was one resident under hospice care.

LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed four residents in care and two staff members on the floor. There were five private rooms. Rooms were provided with furniture in good repair, clean linens, and adequate storage space. Smoke, carbon monoxide detector and auditory alarms were tested to be operational. Bathrooms observed to be in good repair; and provided with handrails and nonskid-floor mat. Hot water was measured at 113 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were rendered inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Side exit doors were self closing. LPA Marin discussed the COVID 19 mitigation of the facility. LPA discussed the Assembly Bill (AB) 665 which requires that a licensee of any adult or senior care residential facility that has internet serviceto 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 also provided guidance on the Guardian system. LPA directed AD to send all general reports and correspondence to CCLASCPOrangeCountyRO@dss.ca.gov

For this visit, no citation was issued.

LPA Marin conducted an exit interview with AD Baha and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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