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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880860
Report Date: 02/22/2023
Date Signed: 02/22/2023 11:55:01 AM


Document Has Been Signed on 02/22/2023 11:55 AM - 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 HOMECAREFACILITY NUMBER:
361880860
ADMINISTRATOR:SALDIVAR, BRYANT JFACILITY TYPE:
740
ADDRESS:9154 BELLFAST ROADTELEPHONE:
(909) 601-5154
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:12CENSUS: 3DATE:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Bryant Saldivar, LicenseeTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted a case management deficiency visit. The case management visit is in response to a deficiencies cited at the facility. LPA met with Licensee Bryant Saldivar and explained the purpose of the visit.

LPA read a notification of fee increase to resident #1’s (R1’s) Power of Attorney (POA) dated 10/07/2021, notifying the POA that their “new payment is $3,000 starting November 1, 2021,” signed by the Licensee. LPA review of R1’s “Admission Agreement and Contract” revealed that R1’s total monthly fees were 2500; therefore, R1’s monthly fees would increase by $500.00 according to the notification to R1’s POA dated 10/07/2021. Page 15 of R1’s Admission Agreement and Contract states, “The facility reserves the right to increase the basic monthly fee and fees for its levels of care by providing a 60-day notice”. LPA interview with R1’s POA revealed that they were notified by the Licensee of the $500.00 fee increase effective November 1, 2021.

LPA also discovered during a facility file audit that R1 was accepted as a resident without a medical assessment, signed by a physician.

Based on observations made during today’s inspection, two ( 2) deficiencies was cited per Title 22, Division 6, of the California Code of Regulations (CCR) and the Health and Safety Code. An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were given to the Licensee.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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 2


Document Has Been Signed on 02/22/2023 11:55 AM - 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: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2023
Section Cited

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Health and Safety Code section 1569.655(a)
a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services...

This requirement was net met as evidenced by:
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Licensee shall read the Health and Safety Code section 1569.655 (a) and submit a letter of understanding to LPA by the POC due date.
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Based on file review & interview, the Licensee did not ensure to provide resident # 1 (R1) representative(s) at least 60-day notification of fee increase., which poses a health, safety, and personal rights violations of clients in care.
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Type B
02/27/2023
Section Cited

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87458 Medical Assessment (a)
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment..

This requirement was net met as evidenced by:
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Licensee shall read 87458 Medical Assessment (a) and submit a letter of understanding to LPA by the POC due date.
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Based on file review & interview, the Licensee did not ensure that R1 had a medical assessment prior to admission to the facility, which poses a health, safety, and personal rights violation of clients 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2