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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604268
Report Date: 10/13/2023
Date Signed: 10/13/2023 06:29:08 PM

Document Has Been Signed on 10/13/2023 06:29 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:RUSSELL HOME ALPINEFACILITY NUMBER:
374604268
ADMINISTRATOR:RUSSELL, KATRINAFACILITY TYPE:
735
ADDRESS:2620 VIA VIEJAS AVETELEPHONE:
(619) 612-2271
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY: 4CENSUS: 4DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Licensee Stacey RussellTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct the required annual licensing inspection. LPA was granted entry into the facility by Licensee Russell identified herself, and stated the purpose of today’s visit, to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. There were 4 clients and 2 staff present during today's visit. LPA Correia conducted a general overall inspection. The facility serves 4 clients, age 18 to 59, and all of whom are ambulatory.

The facility temperature was 76 degrees Fahrenheit at the time of the visit. The client bathroom's hot water temperature measured 120 degrees Fahrenheit. Disinfectants, cleaning solutions, poisons were inaccessible to clients. All of the client rooms were equipped with the required furnishings. Client bathrooms were observed to be sanitary and equipped with the required supplies. Grab bars were present for showers used by clients. Bathtubs and showers had nonskid flooring and grab bars. Lighting was maintained in hallways and passages to client bathrooms. Licensee provided each client with clean linen in good repair, and sufficient hygiene products for personal use. LPA Correia observed smoke alarms, and carbon monoxide detectors throughout the facility that were in operable condition. Per Licensee Russell there are no weapons and/or ammunition housed in the facility. The facility has a pool with a 6 foot self closing/latching gate with a dead bolt.

The facility is stocked with a 2 day supply of perishable and 7 day supply of nonperishable food items. The food was observed properly stored. Medications are stored in a locked office and administered according to the label instructions. The facility's last disaster drill was conducted on 9/22/2023.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: RUSSELL HOME ALPINE
FACILITY NUMBER: 374604268
VISIT DATE: 10/13/2023
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Per staff records reviewed, individuals subject to a criminal record review obtained clearance and/or an exemption; staff responsible for direct care and supervision have current First Aid and CPR training. Administrator Certificate expires 09/25/2023.

Based on today's visit, there were no deficiencies observed at this time in the areas evaluated. An exit interview was conducted with Licensee Russell and Administrator Shontel Grivno and were provided a copy of this report and licensee/appeal rights (LIC 9058 01/16) were provided and, their signature on this form acknowledges receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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