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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604618
Report Date: 12/02/2024
Date Signed: 12/02/2024 12:29:10 PM

Document Has Been Signed on 12/02/2024 12:29 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ALPINE VIEW LODGEFACILITY NUMBER:
374604618
ADMINISTRATOR/
DIRECTOR:
REYNOLDS, ANGELAFACILITY TYPE:
740
ADDRESS:973 ARNOLD WAYTELEPHONE:
(626) 437-5821
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY: 38CENSUS: 31DATE:
12/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee Helen QianTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Alyssa Ramirez, made an unannounced visit to conduct the required One-Year Inspection. LPA was granted entry into the facility by Licensee Helen Qian, after identifying herself and stating the purpose of the inspection. Facility serves elderly residents ages 60 and above; approved for thirty-eight (38) bedridden residents and approved hospice waiver for fifteen (15) residents. The facility is also approved for a secured perimeter with no water feature on the premise. Facilities current census is thirty-one (31).

LPA was accompanied by staff during a tour of the facility. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. PPE supplies are on-site. Passageways were free from obstructions.

Resident rooms were equipped with required furnishings. Hot water temperature accessible to clients were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) and first aid kit (s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Facility has sufficient food supply. Centrally stored medications were properly stored and locked in cabinets.

LPA reviewed staff and resident files. Files were complete and secured in a locked area.

An exit interview was conducted with Licensee Qian, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. Their signature on this form acknowledges receipt and a copy of the report was given to Licensee Qian.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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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