Community Care Licensing

Document Has Been Signed on 05/20/2024 03:25 PM - It Cannot Be Edited

FACILITY NAME:	ALPINE BOARD AND CARE		FACILITY NUMBER:	345002989
ADMINISTRATOR/ DIRECTOR:	NOVELL, ALEX		FACILITY TYPE:	740
ADDRESS:	6725 LINCOLN OAKS DRIVE		TELEPHONE:	(650) 771-4466
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY: 6		CENSUS: 5	DATE:	05/20/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:50 AM
MET WITH:	Alex Novell, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

SUPERVISORS NAME: Anthony Perez LICENSING EVALUATOR NAME: Michael Hood LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024

Link to Parent Document Below:

FACILITY NAME: ALPINE BOARD AND CARE	FACILITY NUMBER: 345002989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2024

Type A

Section Cited

CCR

87202(a)(1)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the facility did not ensure to obtain a fire clearance for more than four (4) nonambulatory residents prior to retaining more than four (4) nonambulatory residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2024
	Plan of Correction
1 2 3 4	Facility is in the process of obtaining a fire clearance for six (6) nonambulatory. LPA will follow up with facility regarding status of fire clearance.

Type A

Section Cited

CCR

87309(a)

(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 observations, facility did not ensure that all disinfectants were locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2024
	Plan of Correction
1 2 3 4	Facility will ensure that all disinfectants are locked and inaccessible to the residents in care. Facility locked disinfectants during visit and LPA cleared deficiency at conclusion of visit.

SUPERVISOR'S NAME: Anthony Perez LICENSING EVALUATOR NAME: Michael Hood LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024

Link to Parent Document Below:

FACILITY NAME: ALPINE BOARD AND CARE	FACILITY NUMBER: 345002989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2024

Type A

Section Cited

CCR

87355(j)

(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, facility did not ensure that a criminal record clearance was obtained for one (1) staff member, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2024
	Plan of Correction
1 2 3 4	Facility will complete a statement of understanding regarding criminal background clearances and ensure that new staff obtain a criminal background clearance before working with residents. Facility will submit statement to LPA by POC due date. A civil penalty in the amount of $500 was assessed for today's date regarding staff not having a criminal background clearance.

Section Cited

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

SUPERVISOR'S NAME: Anthony Perez LICENSING EVALUATOR NAME: Michael Hood LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024

Link to Parent Document Below:

FACILITY NAME: ALPINE BOARD AND CARE	FACILITY NUMBER: 345002989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2024

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, facility did not ensure that initial training was being completed for all care staff in accordance with Health and Safety code, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2024
	Plan of Correction
1 2 3 4	Facility will ensure that initial training is completed for all staff in accordance with Health & Safety code. Facility will submit documentation of missing training to LPA by POC due date of 6/9/2024.

SUPERVISOR'S NAME: Anthony Perez LICENSING EVALUATOR NAME: Michael Hood LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024

Link to Parent Document Below:

FACILITY NAME: ALPINE BOARD AND CARE	FACILITY NUMBER: 345002989
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2024

Type B

Section Cited

HSC

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
1 2 3 4	Based on observation and records reviewed, facility did not ensure to conduct and document quarterly drills, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2024
	Plan of Correction
1 2 3 4	Facility will ensure that quarterly drills are completed and documented at the facility. Facility will submit documentation for first quarterly drill by POC due date of 6/09/2024.

Type B

Section Cited

CCR

87705(c)(4)(A)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records reviewed, facility did not ensure that one (1) resident with a dementia diagnosis was receiving night supervision in accordance with their pre-admission appraisal, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2024
	Plan of Correction
1 2 3 4	Facility will submit an updated LIC 500 to LPA indicating at least one night staff awake and on duty at night by POC due date of 6/09/2024.

SUPERVISOR'S NAME: Anthony Perez LICENSING EVALUATOR NAME: Michael Hood LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024