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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604268
Report Date: 01/02/2025
Date Signed: 01/02/2025 03:08:54 PM

Document Has Been Signed on 01/02/2025 03:08 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:RUSSELL HOME ALPINEFACILITY NUMBER:
374604268
ADMINISTRATOR/
DIRECTOR:
RUSSELL, KATRINAFACILITY TYPE:
735
ADDRESS:2620 VIA VIEJAS AVETELEPHONE:
(619) 612-2271
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY: 4CENSUS: 4DATE:
01/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee Stacey RussellTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection to ensure substantial compliance with Title 22 regulations. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee Stacey Russell.

According to the facility’s license, there may be a maximum of four (4) ambulatory clients. During today’s inspection facilities census was four (4) ambulatory clients.

LPA, accompanied by staff, toured the interior and exterior of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Facility had sufficient food supply. The facility had sufficient space and equipment to facilitate meetings and client activities.
Hot water temperature at taps accessible to clients were also compliant.

There were no sharp objects or toxic chemicals/poisons accessible to clients. No pools or bodies of water were observed on the premises. Emergency lighting facility telephone, fire extinguishers and first aid kit were present.

LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility.

No deficiencies were cited during today's annual inspection.

An exit interview was conducted with Licensee to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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