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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004497
Report Date: 01/06/2023
Date Signed: 01/11/2023 10:01:24 AM

Document Has Been Signed on 01/11/2023 10:01 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
SACRAMENTO AC/SC, 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:
01/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ian Larosa TIME COMPLETED:
03:45 PM
NARRATIVE
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LPA Kesha Lewis made an unannounced health and safety check. LPA met with Staff. LPA explained the purpose of the visit to conduct a health and safety check of the facility. The facility had recently been with out Power.

Incident from 1/03/2023. LPA was informed that the facility has been without power since 12/31/22. The facility was informed by PG&E that a tree had fallen on the power line and disrupted service to the area. The facility has relocated to The La Qunita Inn located in Stockton. There are five residents in three rooms.

Residents returned to facility on 01/05/2033 at approximately 10:00AM. LPA observed staff on duty and some residents using the activity area to watch TV. LPA toured the facility. The facility room temperature was measured at (71) degrees. Water temperature in bathroom was measured at 110 degrees. LPA checked for medications, food/snacks and resident files.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. The facility has a sufficient 2 day supply of perishable food and 7 day non perishable food.

Deficiencies are being cited from the incident on 01/03/2023 pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and a copy of the report left at facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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 01/11/2023 10:01 AM - It Cannot Be Edited


Created By: Kesha Lewis On 01/06/2023 at 02:12 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: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited
CCR
87405(h)(4)(5)

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Administrator - Qualifications and Duties. The administrator shall perform the following duties…(4) Recruit, employ and train qualified staff… (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs. This requirement is not met as evidenced by:
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Licensee/Administrator shall submit to LPA a written statement of understanding regarding Administrator Qualifications and Duties regulation section 87405 and its requirements by POC due date.
Kesha.Lewis@dss.ca.gov
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Based on incident from 1/3/23 administrator did not insure residents in care had basic services after a power outage ( heat, power, food), and did not report the incident to CCL until after a Health and safety check was conducted by LPA Johnson. This poses a immediate health and safety risk to clients in care.
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Type B
01/13/2023
Section Cited
CCR87211

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by:
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Licensee will submit a proposal for a Plan of Correction by Plan of Correction due date for review and approval by CCLD.
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An incident report for the facility power outage occurring on 12/31/2022 through 01/03/2023 was not reported to Community Care Licensing until LPA Johnson was notified by other means on 01/03/2023 which is beyond the required regulatory time frame. This poses a potential risk to the health, safety and personal rights of residents 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:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023


LIC809 (FAS) - (06/04)
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