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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 535002328
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:51:31 PM

Document Has Been Signed on 04/27/2023 02:51 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:ALPINE HOUSEFACILITY NUMBER:
535002328
ADMINISTRATOR:SANDERS, LAURAFACILITY TYPE:
735
ADDRESS:250 MAIN STREETTELEPHONE:
(530) 623-1200
CITY:WEAVERVILLESTATE: CAZIP CODE:
96093
CAPACITY: 6CENSUS: 4DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Tarryn Sanders, and Fallyn MiningerTIME COMPLETED:
03:00 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Staff members Tarryn Sanders and Fallyn Mininger.

This facility has six private resident rooms and one has a full private bathroom. There are two full common bathrooms and one locked staff bathroom. The kitchen and dining area were inspected. The main entrance to this program is on the side of the building that is the office area that also stores medication. The facility has an ample supply of perishable and nonperishable food.

Several topics were discussed.

No deficiencies cited.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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