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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002989
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:36:09 PM


Document Has Been Signed on 05/15/2024 02:36 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: 5DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Alex Novell, AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 5/15/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA interviewed two (2) residents during inspection. LPA reviewed three (3) resident files and one (1) staff file. Facility has a current copy of certificate of liability insurance and LPA obtained a copy.

As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to complete annual inspection.

Exit interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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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