<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002989
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:38:34 PM

Document Has Been Signed on 01/21/2025 03:38 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ALPINE BOARD AND CAREFACILITY NUMBER:
345002989
ADMINISTRATOR/
DIRECTOR:		NOVELL, ALEXFACILITY TYPE:
740
ADDRESS:6725 LINCOLN OAKS DRIVETELEPHONE:
(650) 771-4466
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 4DATE:
01/21/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Shanique Naulty, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:50 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
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with caregiver, Shanique Naulty, to conduct a case management health and safety check. LPA spoke with Administrator, China Washington, via telephone call, who gave permission to have caregiver sign report.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and five (5) bathrooms for resident use, along with one (1) bedroom and one (1) bathroom for staff. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. Hot water temperature was observed to be 118.3 degrees F.

LPA reviewed four (4) resident records and two (2) staff records. LPA observed staff on the premises to have a criminal background clearance on file.

As a result of today's inspection, no deficiencies are being cited. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1