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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002989
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:25:03 PM


Document Has Been Signed on 01/09/2024 02:25 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ALPINE BOARD AND CAREFACILITY NUMBER:
345002989
ADMINISTRATOR:NOVELL, ALEXFACILITY TYPE:
740
ADDRESS:6725 LINCOLN OAKS DRIVETELEPHONE:
(650) 771-4466
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 2DATE:
01/09/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:China Washington, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the care home unannounced on 1/9/24 to conduct a post licensing visit.

A complete tour of the facility was conducted and there are currently two (2) residents in care. There are six (6) bedrooms and five (5) bathrooms for resident use, along with one (1) bedroom and one (1) bathroom for staff. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained.

LPA observed that there are locked cabinets for knives and medications. LPA checked the kitchen area for the ability to prepare and store food. Care home has the required (2) two-day perishable and (7) seven-day non-perishable food supply on hand.

LPA observed the backyard and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. First aid kit to be maintained and ready for emergency use. Smoke detectors and carbon monoxide detectors are hard wired and functioning.

No deficiencies were cited at today's visit. Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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