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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880860
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:19:41 PM

Document Has Been Signed on 03/14/2025 03:19 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALPHALIFE HOMECAREFACILITY NUMBER:
361880860
ADMINISTRATOR/
DIRECTOR:		SALDIVAR, BRYANT JFACILITY TYPE:
740
ADDRESS:9154 BELLFAST ROADTELEPHONE:
(909) 601-5114
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 12CENSUS: 3DATE:
03/14/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Yanira SaldivarTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced health and safety visit at the facility.

At 1:30 p.m. LPA knocked on the door, and no one answered. LPA called the facility telephone number and left a message for a return call. At approximately 1:45 p.m. LPA observed staff, Yanira Saldivar arriving at the facility. LPA informed staff Saldivar the purpose of the visit and was granted entry into the facility.

LPA asked staff Saldivar if who was in the facility supervising the residents while she was out, Saldivar stated her son, who is 17 years of age.

LPA conducted a tour of the facility and observed facility's food supply, personal hygiene supplies, telephone service, emergency telephone numbers, water and facility temperatures. LPA observed resident #1 (R1) was sleeping in their bedroom, resident #2 (R2) in their bedroom sitting in a recliner chair, and resident #3 (R3) in their bedroom sitting in a wheelchair.

Based on LPA observations, deficiencies are being cited in accordance with Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report and correction plans were discussed. Report copies with appeal rights were provided to staff Saldivar at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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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Document Has Been Signed on 03/14/2025 03:19 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/14/2025 at 02:40 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ALPHALIFE HOMECARE
FACILITY NUMBER: 361880860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2025
Section Cited
CCR
87411(a)

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87411 Personnel requirements - General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs..this requirement is not met as evidenced by:
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The Licensee/Administrator shall submit a statement of understanding of the regulation cited by POC due date.
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Based on LPA observations, LPA observed three (3) residents left without qualified staff supervision; which poses an immediate health, safety, and person rights risk to persons in care.
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Type A
03/17/2025
Section Cited
CCR87411(b)

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87411 Personnel requirements - General (b) All persons...who supervise or care for residents shall be at least eighteen (18) years of age. This requirement is not met as evidenced by:
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The Licensee/Administrator shall submit a statement of understanding of the regulation cited by POC due date.
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Based on LPA observation, staff's son who is 17 years old was left to supervise residents in care; which poses an immediate health, safety, and personal right risks to persons in care.
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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
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