397004497-7-14-2023-27-AS-MBIR-CTQSRW-20230714140701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004497
Report Date: 07/14/2023
Date Signed: 07/14/2023 02:07:18 PM

Document Has Been Signed on 07/14/2023 02:07 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	NEW HOPE GUEST HOME-ALPINE		FACILITY NUMBER:	397004497
ADMINISTRATOR:	ROBERT FELIX		FACILITY TYPE:	740
ADDRESS:	3008 W. ALPINE AVENUE		TELEPHONE:	(209) 941-0519
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	6	CENSUS: 5	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Robert Felix		TIME COMPLETED:	02:15 PM

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	On 7-14-23 at 9:50am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Robert Felix and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly with a current census of 5. Facility has 5 bedrooms and 2 bathrooms for resident use. Three bedrooms are resident use. Facility has a dining area off the kitchen and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care 5 non-ambulatory residents, 1 resident is on hospice, and 0 bedridden. Water temperature reads 105F to 120F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 2-3-23. Facility has an emergency food and water kit. LPAs observed carpet cleaner, paint, and gardening hedge clippers accessible to residents in care during today's visit. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff. During this inspection 5 resident files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. LPA completed 1 resident interviews and 2 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and update to date per regulatory requirements. {Cont on 809C}

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HOPE GUEST HOME-ALPINE	FACILITY NUMBER: 397004497
	VISIT DATE: 07/14/2023

NARRATIVE

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Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. Upon review resident records, it was determined that facility is providing care to resident1 (R1) without a hospice waiver on file. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 809D. Exit interview was held and a report was given to Administrator Robert Felix. Appeal rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2023 02:07 PM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HOPE GUEST HOME-ALPINE	FACILITY NUMBER: 397004497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, cleaning fluid, paint can, and gardening hedge clippers were accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2023
	Plan of Correction
1 2 3 4	Licensee locked dangerous supplies to secure location during LPA's visit Licensee will submit a plan to ensure toxins and other dangerous items will remain inaccessible to residents in care. Plan to be submitted to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2023 02:07 PM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HOPE GUEST HOME-ALPINE	FACILITY NUMBER: 397004497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not ensure a quarterly fire drill due in June of 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2023
	Plan of Correction
1 2 3 4	Licensee will ensure fire drill to be conducted by POC due date and submit proof of completion to LPA by POC due date. Licensee will submit a plan which ensures on-going timely fire drills conducted at least quarterly. Plan to be submitted to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2023 02:07 PM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HOPE GUEST HOME-ALPINE	FACILITY NUMBER: 397004497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)

87632 Hospice Waiver. (a) In order to accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice waiver from the Department... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee is currently providing hospice care for resident1 (R1) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2023
	Plan of Correction
1 2 3 4	Licensee will submit a hospice waiver request to LPA by POC due date. Licensee will read regulation 87632 and submit a signed declaration of understanding to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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