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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004497
Report Date: 07/12/2021
Date Signed: 07/12/2021 11:15:49 AM

Document Has Been Signed on 07/12/2021 11:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NEW HOPE GUEST HOME-ALPINEFACILITY NUMBER:
397004497
ADMINISTRATOR:ROBERT FELIXFACILITY TYPE:
740
ADDRESS:3008 W. ALPINE AVENUETELEPHONE:
(209) 941-0519
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 5DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Robert FelixTIME COMPLETED:
11:10 AM
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
On 7/12/21 at 9:35am, LPA Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the Licensee Robert Felix and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5. Facility has 3 bedrooms with an extra 1 bedroom for isolation as needed. There is a dining area off of the kitchen area. Facility also has 2 bathrooms. There is a large ramp leading to the entry way of the facility. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. Hand sanitizer is available throughout the facility. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 109.7*F in the bathroom and room temperature reads 72*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 4/3/21. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Robert Felix and a report was given to Robert.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
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