306005364-3-20-2024-22-AS-RQUZ-D3JQZ9-20240320123621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005364
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:37:24 PM

Document Has Been Signed on 03/20/2024 12:37 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 RESIDENCE		FACILITY NUMBER:	306005364
ADMINISTRATOR:	VILLANUEVA SABINO, SOCORRO		FACILITY TYPE:	740
ADDRESS:	17982 LOS TIEMPOS ST		TELEPHONE:	(714) 785-9994
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	03/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Socorro Villanueva Sabino, Licensee/Administrator		TIME COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1). Licensee/Administrator (L/AD) Socorro Villanueva Sabino arrived during today's visit and discussed purpose of today's visit. This is a a Residential Care Facility for the Elderly, licensed to provide services to six (6) Non-Ambulatory residents, of which (6) six may be bedridden and has a hospice waiver for (4) four residents. There are no active COVID-19 cases in the facility at this time. There are currently six (6) residents in care at this time, of which (5) five are receiving hospice care services. (SEE LIC 809-D) AD Socorro Villanueva Sabino has an Administrator certificate with expiration date of March 29, 2025. LPA Quiroz along with CG1 toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed Resident 1- Resident 6 in their bedrooms resting with staff conducting frequent round checks. LPA Quiroz interacted and interviewed with Caregivers and 1 of 6 residents during today's visit. LPA Quiroz inspected resident's bedrooms and bathrooms. The water temperature in 2 of 2 resident's bathrooms were recorded to be within normal limits. LPA Quiroz inspected resident's bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has supply of emergency food, water and PPE in the garage area readily available for staff and residents in care. The Fire extinguisher observed last serviced on September 18,2023. LPA Quiroz observed functional and operational washer and dryer in the laundry room area. During today's visit, on or about 9:42am LPA Quiroz observed CG1 walking away from secured sharps drawer where knives are stored leaving the key in the cabinet, but was observed to go back and locked and secured drawer. On or about 11:46am, LPA Quiroz observed CG2 walking away from medication cabinet leaving the medication cabinet opened to assist a Resident, and was observed to go back to medication cabinet to lock and secure it. (SEE LIC 9102 TV) LPA Quiroz toured the outside of the facility and observed seating and shaded area in the backyard for residents and visitor's enjoyment. CONTINUED ON LIC 809-C PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALPINE RESIDENCE	FACILITY NUMBER: 306005364
	VISIT DATE: 03/20/2024

NARRATIVE

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CONTINUED...LPA Quiroz reviewed 6 of 6 resident records and 3 of 3 personnel files.

Faciity cited during today's visit.

During today's visit, LPA Quiroz provided Consultation on Title 22 and Infection control. An exit interview was conducted with (L/AD) Socorro Villanueva Sabino, and a copy of this report, LIC 809-D, LIC 9102-Technical Violation, Appeal Rights and LIC 811- Confidential names, were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/20/2024 12:37 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALPINE RESIDENCE	FACILITY NUMBER: 306005364
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)

In order to accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shallhave obtained a facility hospice care waiver from the department... This requirement is not met as evidenced by: (5) Five residents receiving hospice care services were observed during today's visit.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], 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: 03/27/2024
	Plan of Correction
1 2 3 4	Licensee Socorro Villanueva Sabino will read and understand CCR 87632 and submit proof of understanding and submit a hospice waiver increase by POC due date of 3/27/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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