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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004524
Report Date: 05/13/2025
Date Signed: 05/13/2025 06:11:32 PM

Document Has Been Signed on 05/13/2025 06:11 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ALPINE B II CAREFACILITY NUMBER:
306004524
ADMINISTRATOR/
DIRECTOR:		KAHDIJA"HEIDI"BAHAFACILITY TYPE:
740
ADDRESS:26352 PAPAGAYO DRIVETELEPHONE:
(949) 454-8349
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
05/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Heidi Baha- AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Administrator (Admin) Heidi Baha and explained the reason for the visit. Administrator (Admin) Guibilondo holds a valid certificate expiring on March 1, 2027.

The facility is a single story structure and is licensed to provide services for age range 60 and over for six non-ambulatory. A waiver was granted to provide hospice services to three residents at one time. During today's visit, two residents were under hospice care, two caregivers were on duty providing care to five residents who were observed relaxing in the living room and their respective bedrooms.

LPA toured the physical plant with Admin. Facility is clean, operational, and in good repair with the exception of one resident bedroom. The hardwood floor and closet door are being repaired due to the water damage. The Department was not notified of the alterations being made prior to the renovations. LPA observed five resident bedrooms and bathrooms. There is one additional staff bedroom shared by two staff. Resident bedrooms had all required furnishings. Bathrooms were in compliance, clean, and operational. The hot water temperature measured at 107.2, 105.8, 105.9, 105.2, and 105.8 degrees Fahrenheit in the resident bathrooms. All common areas were inspected including the attached two car garage. LPA reviewed the Emergency Disaster Plan (LIC610E) and observed sufficient water in the pantry walk in closet. There were no emergency food observed. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen and garage. LPA toured the exterior portion of the facility.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/13/2025 06:11 PM - It Cannot Be Edited


Created By: Jessica Cho On 05/13/2025 at 04:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALPINE B II CARE
FACILITY NUMBER: 306004524

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
§1569.625 Staff training; legislative findings; contents (b) (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above in two out of two staff files reviewed, S1 and S2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2025
Plan of Correction
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Administrator will ensure annual trainings are held, documented, and proof of complete 40 hour training will be submitted to LPA via email by POC due date.
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements – General (f)All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not completing the LIC503 for S2 and TB testing in two out of two staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2025
Plan of Correction
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Administrator stated that proof of health screening for S2 and TB test results for S1 and S2 will be provided to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ALPINE B II CARE
FACILITY NUMBER: 306004524
VISIT DATE: 05/13/2025
NARRATIVE
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The outdoor passageway is free of obstruction. The exit gates were in good repair. LPA observed sufficient seating and shading. The fire extinguishers in the kitchen and garage were invalid expiring on July 19, 2023. The auditory devices and smoke/carbon monoxide detectors were tested and operational.

Emergency evacuation drills are not conducted quarterly. The facility land line number, (949) 454-8349, was tested and remains available. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available in an incorrect size and posted on the bulletin board.

LPA conducted a review of all residents and two staff files. Discrepancies observed in the resident files as the medical assessments (LIC602s) were not updated annually in three out of five residents. Discrepancies observed in the staff files as the staff did not complete 40 hours of annual training, the health screening was not completed for one staff and Tuberculosis (TB) tests were incomplete in two out of two staff files reviewed. The medications were audited in two out of five residents. No discrepancies noted. No interviews were conducted due to time constraints.

The following items were addressed with the Admin: to conduct quarterly emergency drills, to notify the Department prior to any alterations, to ensure 40 hour staff training is completed annually, to ensure fire extinguishers are current, to complete Health Screening (LIC503) for Staff #2 (S2) and TB tests for both staff, and to obtain medical assessments (LIC602s) for three out of five residents.

Based on the observations made during today's visit, deficiencies are being cited. See attached LIC809Ds. Civil penalties for repeat violations are being assessed. See LIC421FCs. Advisory Notes (LIC9102s) are being issued.

An exit interview was conducted with Administrator Heidi Baha, and a copy of this report including the LIC809C, LIC809Ds, LIC9102s, LIC421FCs, LIC811s, and the appeal rights were provided at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 06:11 PM - It Cannot Be Edited


Created By: Jessica Cho On 05/13/2025 at 05:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALPINE B II CARE
FACILITY NUMBER: 306004524

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in three out of five residents which poses a potential health, safety, and/or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
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Administrator stated that proof of LIC602s for R2, R3, and R4 will be submitted to LPA via email by POC due date.
Type B
Section Cited
HSC
1569.695(c)
1569.695(c) (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
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Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety, and/or personal rights risk to persons in care.
POC Due Date: 05/27/2025
Plan of Correction
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Administrator statedd that proof of emergency drill conducted will be submitted to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 06:11 PM - It Cannot Be Edited


Created By: Jessica Cho On 05/13/2025 at 05:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALPINE B II CARE
FACILITY NUMBER: 306004524

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility's two fire extinguishers have not been inspected in approximately two years and the Department was not notified of the alterations being made in a resident's bedroom due to water leak which poses a potential safety risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
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Licensee stated proof of fire extinguishers inspected or replaced as well as a letter indicating the bedroom alteration start/end date/plan will be submitted to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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