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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005364
Report Date: 03/29/2022
Date Signed: 03/29/2022 02:35:25 PM


Document Has Been Signed on 03/29/2022 02:35 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 RESIDENCEFACILITY NUMBER:
306005364
ADMINISTRATOR:VILLANUEVA SABINO, SOCORROFACILITY TYPE:
740
ADDRESS:17982 LOS TIEMPOS STTELEPHONE:
(714) 785-9994
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
03/29/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cory Sabino, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Cory Sabino, Administrator after explaining the purpose of the visit.

At approximately 1:35pm, LPA accompanied by administrator toured the inside and outside of the facility. There is currently six (6) residents in care, with three (3) residents currently on hospice. The residents are observed to be relaxing in their bedrooms or in the common areas and appears well taken care of. The four (4) bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility appears to be clean, sanitary and free of odors in all areas inspected.

Sharp instruments are kept in a cabinet secured by a key lock. Cleaning supplies and toxic substances are securely stored under lock. LPAs observed the facility has COVID-19 Precautions posters, required department postings as well as handwashing signs. Facility has an adequate supply of PPE. A LIC808 Mitigation Plan has been submitted on 04/27/2021.

LPAs observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility. Outdoor furniture is present for the residents' enjoyment in the backyard. The perimeter gates are self-latching and can easily be opened in an evacuation.

Staff present is observed to be correctly associated in Guardian. The Administrator's license is up to date and posted in a central location.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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