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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880860
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:23:45 PM

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
RIVERSIDE, CA 92507
FACILITY NAME:ALPHALIFE HOMECAREFACILITY NUMBER:
361880860
ADMINISTRATOR:SALDIVAR, BRYANT JFACILITY TYPE:
740
ADDRESS:9154 BELLFAST ROADTELEPHONE:
(909) 601-5154
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:12CENSUS: 4DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Bryant SaldivarTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Williams identified herself to Administrator, Bryant Saldivar and discussed the purpose of the visit. LPA Williams was asked to sign-in and provide temperature reading upon arrival. Saldivar confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Williams conducted a tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA Williams observed appropriate postings throughout the facility, including COVID-19 symptoms postings and face coverings postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Williams observed that one facility staff member was not wearing a face covering. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

Based on observations made during today’s inspection, two deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA Williams observed that two portable gates were obstructing the facility's hallway passageway where resident bedrooms are located. LPA Williams also observed that two exterior gates where equipped with a padlock without proper fire clearance.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 6
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
RIVERSIDE, CA 92507

FACILITY NAME: ALPHALIFE HOMECARE
FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed that there were two gates erected in the facility hallway where resident bedrooms reside. The gates obstruct the hallway passageway, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2021
Plan of Correction
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Licensee agreed to remove gates in the facility hallway and send proof to the Department by POC date.
Type B
Section Cited
CCR
87202(a)
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 of 2 gates located outside. The 2 gates were equipped with a padlock, without any other emergency exit from the courtyard. LPA observed that there was no fire clearance or exception on file for locked perimeter. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2021
Plan of Correction
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Licensee agreed to remove padlocks on both gates or send the Department an excpetion request by POC date. If Licensee chooses to remove padlocks, the Licensee agreed to send proof that the padlocks were removed by POC date,
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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
RIVERSIDE, CA 92507
FACILITY NAME: ALPHALIFE HOMECARE
FACILITY NUMBER: 361880860
VISIT DATE: 11/02/2021
NARRATIVE
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LPA Williams also issued two technical violations for Reporting Requirements & Maintenance and Operation. The Administrator confirmed that the facility did not provide the Department with COVID-19 Mitigation Plan (LIC 808) LPA Williams also observed that one staff member was not wearing a face covering upon arrival to the facility.

An exit interview was conducted where this report was discussed and a copy was provided to Saldivar at the conclusion of the inspection.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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