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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808095
Report Date: 06/13/2024
Date Signed: 07/02/2024 10:30:10 AM

Document Has Been Signed on 07/02/2024 10:30 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ALPINE TERRACEFACILITY NUMBER:
370808095
ADMINISTRATOR/
DIRECTOR:		DEBORAH JOHNSTONFACILITY TYPE:
735
ADDRESS:1544 ALPINE TERRACETELEPHONE:
(619) 445-8716
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY: 6CENSUS: 4DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee Deborah JohnstonTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst’s (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. Facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee Deborah Johnston. The facility is currently licensed for six (6) ambulatory clients. During today’s inspection, there was a total of four (4) ambulatory clients in care..

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected resident bedrooms. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens, hygiene supplies. Hot water temperature was compliant.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. Medications were labeled, as required, and stored in locked areas. Facility has swimming pool, The facility has a waiver allowing a sliding door to be unlocked to access the pool. The licensee honors the conditions for this waiver by ensuring that all of the clients are able to swim and maintaining her water safety certificate. Per staff no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) and first aid kit was present. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients and reviewed multiple staff and client records/files. The files which LPA reviewed contained required documents.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction was jointly developed with Licensee. An exit interview was conducted with Licensee, to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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Document Has Been Signed on 07/02/2024 10:30 AM - It Cannot Be Edited


Created By: Alyssa Ramirez On 06/13/2024 at 10:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ALPINE TERRACE
FACILITY NUMBER: 370808095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one (C1) out of four clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Licensee will ensure that C1 gets a signed physician's report completed and will email to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Simon Jacob
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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