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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880860
Report Date: 04/11/2022
Date Signed: 04/11/2022 02:15:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Rohit Lama
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220405151228
FACILITY NAME:ALPHALIFE HOMECAREFACILITY NUMBER:
361880860
ADMINISTRATOR:SALDIVAR, BRYANT JFACILITY TYPE:
740
ADDRESS:9154 BELLFAST ROADTELEPHONE:
(909) 601-5154
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:12CENSUS: 3DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bryant Saldivar, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff placing resident in restraints
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rohit Lama made an unannounced visit to initiate an investigation and deliver findings for the allegation listed above. LPA met with the Administrator, Bryant Saldivar.

The investigation consisted of interviews and a tour of the facility. The allegation indicates that the facility is using restraints on Resident #1 (R1)'s hands. During the tour of the facility, it was noted that R1 did in fact have hand mitten restraints in place. When the Administrator was asked about the hand restraints, it was explained to the LPA that this was being done because R1's family and Attorney-In-Fact had requested the use of the hand restraints. The Administrator stated that the use of hand restraints was requested to maximize R1's safety. No mention of the restraints is seen in R1's Care Plan. Based on the evidence gathered and observations made during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Health and Safety Code 87608(a)(5) is being cited on the attached LIC 9099-D. *****CONTINUED ON LIC 9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20220405151228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ALPHALIFE HOMECARE
FACILITY NUMBER: 361880860
VISIT DATE: 04/11/2022
NARRATIVE
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LPA conducted an exit interview where a copy of this report (LIC 9099, LIC 9099C, and LIC 9099D) was discussed and provided to the Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20220405151228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ALPHALIFE HOMECARE
FACILITY NUMBER: 361880860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2022
Section Cited
HSC
87608(a)(5)
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Postural Supports: Based on the individual's preadmission appraisal... the facility shall provide assistance and care for the resident... Postural supports may be used under the following conditions: (5) Under no circumstances shall postural supports include tying, depriving, or limiting use of a
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Administrator had removed restraints prior to LPA leaving. Administrator needs to read and understand the Regulation Section 87608 - Postural Support. Administrator needs to train all staff on this regulation as well. Administrator will provide LPA, by POC Due Date (4/12/2022), with a scanned
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resident's hands or feet. This regualtion was not met as evidenced by: Observations made by LPA and Interview with Administrator. This poses as a immediate health and safety risk to resident's in care.
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self-certification document showing understanding of the material, which needs to be signed by all staff.
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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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5