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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004497
Report Date: 07/07/2022
Date Signed: 07/07/2022 03:51:34 PM

Document Has Been Signed on 07/07/2022 03:51 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
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:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Robert FelixTIME COMPLETED:
04:05 PM
NARRATIVE
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On 7/7/22 at 1:38 pm,Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the Administrator 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, and garage 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 between 105*F and 120*F and in the bathroom and room temperature reads 75*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 2/7/22. Facility has an emergency food and water kit. LPA observed toxins located in garage and outside shed accessible to residents in care.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 9099D. Exit interview was held with Robert Felix and a report was given to Robert. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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 07/07/2022 03:51 PM - It Cannot Be Edited


Created By: Michael Bilger On 07/07/2022 at 02:39 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HOPE GUEST HOME-ALPINE
FACILITY NUMBER: 397004497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed cleaning supplies unlocked in the garage and weed killer solution unlocked in a shed outside both accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2022
Plan of Correction
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Licensee secured items during LPA's visit
Licensee will conduct staff training on regulation 87309(a) and submit training date to LPA by POC due date. Proof of training to be submitted to LPA no later than one week from today's date of 7-8-22.
Licensee will read regulation 87309(a) and submit a signed declaration of understanding to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
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