374604618-4-13-2023-08-AS-DNGN-CQUPEH-20230413111511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604618
Report Date: 04/13/2023
Date Signed: 04/13/2023 11:15:16 AM

Document Has Been Signed on 04/13/2023 11:15 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ALPINE VIEW LODGE		FACILITY NUMBER:	374604618
ADMINISTRATOR:	REYNOLDS, ANGELA		FACILITY TYPE:	740
ADDRESS:	973 ARNOLD WAY		TELEPHONE:	(626) 437-5821
CITY:	ALPINE	STATE: CA	ZIP CODE:	91901
CAPACITY:	38	CENSUS: 30	DATE:	04/13/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee Helen Qian and Administrator Angela Reynolds		TIME COMPLETED:	11:20 AM

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) Dang Nguyen conducted an unannounced Case Management Visit to observe the physical plant, review records, and interview staff. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Helen Qian and Administrator Angela Reynolds. On 02-02-2023, the Licensee submitted a written request to the CCLD San Diego Regional Office (RO), applying for approval to lock, from the inside (and not from the outside), one (1) specific perimeter gate located on a fence which surrounds the facility property, thus constituting a "secured perimeter." The request did not involve locking perimeter doors on the facility building itself, and did not involve amending the facility's total capacity, bedridden capacity, or floor plan. On 09-16-2022, the local fire authority, Alpine Fire Protection District, granted a Fire Clearance to the facility. This Fire Clearance included approval for licensee to lock the above mentioned perimeter fence gate. During today’s visit, LPA, accompanied by staff, conducted a tour of the interior and exterior of the facility. The facility’s sketch/floor plan was consistent with the current layout of the facility. The posted evacuation routes reflected that the above-described fence gate will be locked. The staff-alert devices/alarms on each of the facility building's exit doors were working/audible. Carbon monoxide and smoke alarms were functioning. Fire extinguishers had been serviced within the last 12 months. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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: ALPINE VIEW LODGE	FACILITY NUMBER: 374604618
	VISIT DATE: 04/13/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

LPA also reviewed pertinent medical records. Per review of the current residents' LIC624 Physician's Reports: a) 29 of 30 residents were formally diagnosed with either dementia or a similar neuro-cognitive disorder. Resident #1's (R1) LIC624 did not contain a formal diagnosis of dementia or neuro-cognitive disorder. [See LIC811 Confidential Names List for a description of R1.] However, LPA interviewed R1 and observed mild signs of cognitive impairment, which staff interviews corroborated. Facility staff stated they were actively coordinating with R1's doctor to update their respective LIC624; and, b) none of the 30 residents had as their primary diagnosis a mental disorder unrelated to dementia. Also, each resident’s file contained a signed statement from their respective responsible person (or conservator, where applicable), consenting to continued residency even as the facility locks its perimeter fence gate.

In their interviews, the licensee and administrator confirmed: c) without violating residents' personal rights, they attempt to redirect residents who try to leave the facility, d) residents who still insist on leaving are allowed to leave, with staff accompanying them for safety, and e) staff understand that locked perimeter doors/gates are not a substitute for trained staff in sufficient numbers to meet the care and supervision needs of residents.

The facility’s disaster drill logs showed at least one drill per quarter was being conducted on each of its three work shifts. Licensee’s updated Plan of Operation describes the facility’s locked perimeter fence gate.

LPA observed no immediate health or safety issues. No deficiencies were cited during today's visit.

This portion of the application process is complete. Pending CCLD management’s final review and approval, the licensee will be issued an updated license to reflect approval/authorization to have a secured perimeter.

An exit interview was conducted with Qian and Reynolds, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

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