Alpine View Lodge.

Licensing Program Analyst (LPA) David Roman conducted an unannounced Case Management Inspection. LPA D. Roman identified himself to Licensee, Helen Qian, and discussed the purpose of the visit. LPA D. Roman reviewed the unusual incident report with the licensee, identified the resident was having self harming behaviors. LPA D. Roman conducted a staff interview which revealed the resident was attempting to elope, and exhibited SP, in which law enforcement was contacted and the resident was transferred to UCSD Senior MHS. Staff reported to have a family meeting with the residents responsible party to inform that the resident is in need of a higher level of care. The family was in agreement as the resident reported not wanting to return to the facility. LPA D. Roman along with facility staff toured the interior and exterior of the facility and inspected bedrooms and bathrooms. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. The facility has sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents, medication cart is locked. No pools or bodies of water on the premises. An exit interview was conducted with Facility Licensee, Helen Qian.

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.

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Manager Carmen Hall, after identifying herself and stating the purpose of the inspection. Licensee Helen Qian later joined the visit. Facility Profile: 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. LPA was accompanied by Manager Carmen Hall 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. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and Non-skid mats. Hot water temperature accessible to clients were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit (s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed several different types of activities that the residents were participating. [CONTINUED ON LIC 809-C] 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 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors as well as personal shopping. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. LPA reviewed the theft and loss policy and procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. 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.