361880860-10-27-2022-56-AS-RNIS-CKLVBP-20221027161753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880860
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:18:16 PM

Document Has Been Signed on 10/27/2022 04:18 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	ALPHALIFE HOMECARE		FACILITY NUMBER:	361880860
ADMINISTRATOR:	SALDIVAR, BRYANT J		FACILITY TYPE:	740
ADDRESS:	9154 BELLFAST ROAD		TELEPHONE:	(909) 601-5154
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY:	12	CENSUS: 3	DATE:	10/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Bryant Saldivar, Licensee		TIME COMPLETED:	04:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rayshaun Nickolas 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 arrived and met with Licensee Bryant Saldivar and explained the purpose of the visit. LPA was screened for COVID-19 symptoms and asked to sign-in upon arrival. Saldivar confirmed that there are currently no cases/exposures of COVID-19 within the facility. During the inspection, LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA observed appropriate postings throughout the facility, including, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient cleaning/disinfecting provisions. LPA observed facility staff wearing face coverings. 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 (CCLD) guidelines for COVID-19 testing, isolating/quarantining clients. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and emergency personnel in the event the clients presents any COVID-19 symptoms. LPA reviewed clients records during today's inspection. LPA observed and interview a individual volunteering at the facility without criminal record clearance. LPA observed this individual moping in a bedroom and working in the kitchen. The individual states that he/she does not work at the facility but has been visiting for a month. LPA also observed during the client's records review that all clients in care do not have a documented medical assessment, signed by a physician, made within the last year.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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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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
, CA 92507

FACILITY NAME: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
	VISIT DATE: 10/27/2022

NARRATIVE

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Based on observations made during today’s inspection, two (2) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR).

A $500.00 civil penalty has been assessed for the individual volunteering at the facility without a criminal record clearance.

An exit interview was conducted and a copy of this report, LIC 809D, LIC421BG, and Appeal Rights were given to the Licensee.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/27/2022 04:18 PM - It Cannot Be Edited

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
, CA 92507

FACILITY NAME: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in allowing an individual without a criminal records clearance at the facility,which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2022
	Plan of Correction
1 2 3 4	The licensee shall ensure that the individual volunteering at the facility requests a live scan (LIC9163). The Licensee is advised that this individual cannot volunteer or reside at the facility until he/she has a criminal record clearance . Proof of the live scan shall be submitted to the regional office (RO) by 10/28/2022. A civil penalty of $500.00 has been assessed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/27/2022 04:18 PM - It Cannot Be Edited

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
, CA 92507

FACILITY NAME: ALPHALIFE HOMECARE	FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in ensuring that each client had a documentation of a medical assessment signed by a physician, made within the last year, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2022
	Plan of Correction
1 2 3 4	Licensee shall ensure that all clients have LIC 602 physician report completed and signed by a physician within the last year on file. Proof of correction shall be submitted to the regional office (RO) by 11/25/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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