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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002989
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:16:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20231122112651
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
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Alex Novell, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Michael Hood arrived at the facility and met with Administrator, Alex Novell, to deliver findings into the allegation listed above.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 59-AS-20231122112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 345002989
VISIT DATE: 05/15/2024
NARRATIVE
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During visit conducted on 11/29/2023, LPA conducted an inspection of the facility's required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed multiple open containers, including salad dressing, and multiple expired food items, including yogurt and condiments, in the facility's refrigerator. LPA also observed multiple food containers with prepared food that was not dated or labeled. LPA observed staff member (S1) clean refrigerator and purge expired food items during visit conducted on 11/29/2023. During all subsequent visits to the facility during investigation, LPA observed a sufficient supply of food at the facility.

Based on observation, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20231122112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 345002989
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87555(b)(8)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality. (...) Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
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Facility purged food items during visit conducted on 11/29/2023. LPA observed a sufficient supply of food of good quality during all subsequent visits. LPA cleared deficiency at the conclusion of this investigation.
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Based on observation, facility did not ensure food items were of good quality and stored in sealed containers, which poses a potential health, safety, and personal rights risk to the residents in care.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20231122112651

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
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Alex Novell, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident sustained a burn due to staff neglect

Staff did not provide resident's authorized representative with requested documents

Staff are not allowing visitors

Staff are not providing activities for residents
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Michael Hood arrived at the facility and met with Administrator, Alex Novell, to deliver findings into the allegations listed above.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20231122112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 345002989
VISIT DATE: 05/15/2024
NARRATIVE
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Interview with relevant party indicated that resident (R1) sustained a burn while residing at the facility. Interviews conducted with Administrator, China Washington, and staff members (S1 & S2) indicated that they never observed R1 sustain a burn mark while residing at the facility. LPA conducted an interview with R1, who could not recall sustaining a burn while residing at the facility. LPA did no observe a burn mark on R1 during interview.

A review of R1's hospice records dated 10/1/2023 to 12/12/2023 did not indicate that R1 sustained a burn mark during the time that they resided at the facility.

Interview with relevant party indicated that they could not recall requesting documents for R1. Interview with Administrator Washington indicated that any records requested for R1 were provided to the requester within a timely manner.

Interview with relevant party indicated that they were allowed to visit R1 while they resided at the facility. Interviews with Administrator Washington, staff members S1, S2, S3, and S4 stated that they are allowing visitation at the facility. All staff interviews indicated that there is a visitor policy allowing visitation between 9:00 AM to 5:00 PM everyday, but accommodations are made for individuals who cannot visit residents during those hours. Interviews with residents R2, R3, and R4 indicated that they are able to receive visitors at the facility. LPA observed a visitor log for visitors to sign at the conclusion of this investigation.

Interview with relevant party indicated that activities were not provided to R1 in accordance with their admission agreement. LPA reviewed R1's Admission Agreement, which indicates the following: "We shall offer individualized program of recreational activities based on cooperative planning by facility staff, family, physician, and rapport and communication with the resident. We offer responsive, creative, and fluid planning of recreational activities. Residents and families are interviewed to gather information on their personal preferences, beliefs, culture, values, attention span and life experiences to determine activities that residents will enjoy and benefit from." LPA observed that admission agreement was signed by R1's representative on 10/11/2023.

** Report continued on 9099-C **
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
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20231122112651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 345002989
VISIT DATE: 05/15/2024
NARRATIVE
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During visit conducted on 11/29/2023, LPA observed board games, crossword puzzles, and toys available to the residents. LPA observed books and a television in the residents' rooms. Interviews conducted with Administrator Washington, S1, S2, S3, and S4 indicated that the residents are provide resources for activities and encouraged to participate in activities. Interviews with residents R2, R3, and R4 indicated that they have resources for activities

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 6