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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002989
Report Date: 05/20/2024
Date Signed: 05/20/2024 03:34:23 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
05/17/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240517152244
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:
05/20/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:China Washington, AdministratorTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility issued an unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Alex Novell, to open a complaint into the allegation listed above. During today's visit, LPA interviewed Licensee and Administrator, China Washington, and reviewed documentation pertinent to the investigation. LPA reviewed a text authored by Licensee and issued to resident (R1's) responsible party (RP) stating regarding to the text to "consider it as a 30 day notice to take [R1] somewhere else." LPA observed a text authored by Administrator and sent to R1's RP stating to "disregard the 30 day notice."

Based on interviews conducted and records reviewed, 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 Licensee. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
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: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
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 2
Control Number 59-AS-20240517152244
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: 05/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2024
Section Cited
HSC
1569.683(a)
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ยง1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. (...) This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 1269.683. Facility will submit statement of understanding to LPA by POC due date of 6/09/2024.
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Based on interviews conducted and records reviewed, the facility did not issue a lawful 30-day notice to R1's representative regarding eviction, which poses an potential health, safety, and personal rights risk to 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: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC9099 (FAS) - (06/04)
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