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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423960
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:21:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/02/2022 12:21 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:ALPINE CARE ASSISTED LIVINGFACILITY NUMBER:
336423960
ADMINISTRATOR:ILMA R. LEESONFACILITY TYPE:
740
ADDRESS:6562 GOLD DUST STREETTELEPHONE:
(951) 479-5404
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 5DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Alounkone Brooke SanasinhTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this visit for the purpose of an annual inspection. LPA was greeted at the door by a caregiver and granted entry. Upon entry into the facility LPA was requested to sign in. A thermometer was present for monitoring visitors.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures and potential health and safety issues. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions. The facility has PPE supplies, cleaning and disinfection provisions in adequate quantities. The facility has an approved Community Care Licensing mitigation plan in place and have submitted their Infection Control Plan. LPA observed a bedroom set up in the master bedroom closet which is not approved as a resting quarters per their fire clearance and poses a risk to the health and safety of individuals utilizing the space for rest.

Based on the observations made during today’s visit, the following deficiency is being cited per Title 22, Division 6, of the California Code or Regulations.

This reports was reviewed with and a copy was provided to the facility representative.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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 2


Document Has Been Signed on 08/02/2022 12:21 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ALPINE CARE ASSISTED LIVING
FACILITY NUMBER: 336423960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2022
Section Cited

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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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This regulation has not been met as evidenced by: LPA observed a bedroom set up in the master bedroom closet. This poses a risk to the health and safety of those using the space. This is not a cleared space for resting/sleeping per the approved fire clearance.
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 understanding of the regulation section cited.

* A Civil Penalty accompanies this deficiency.

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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2