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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200118
Report Date: 05/31/2022
Date Signed: 05/31/2022 04:40:24 PM

Document Has Been Signed on 05/31/2022 04:40 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ALEXEN HOMEFACILITY NUMBER:
019200118
ADMINISTRATOR:GABRIELE SIBONGAFACILITY TYPE:
735
ADDRESS:15902 VIA DESCANSOTELEPHONE:
(510) 798-4660
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY: 6CENSUS: 6DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:GABRIELE SIBONGA, AdministratorTIME COMPLETED:
04:50 PM
NARRATIVE
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On 5/31/2022 starting at 3:15 p.m., Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Gabriele Sibonga and disclosed the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.

THE FOLLOWING DEFICIENCY WAS OBSERVED:
ยท At 3:15pm, LPA observed lots of flies inside facility mainly in the living room, kitchen area, and dinning area.


The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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 05/31/2022 04:40 PM - It Cannot Be Edited


Created By: Catherine Lin On 05/31/2022 at 04:17 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ALEXEN HOME
FACILITY NUMBER: 019200118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed lots of flies inside the facility mainly in the living room, kitchen area, and dinning area which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
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Administrator agreed to provide a detail planning to keep facility free of flies, and submit the plan to CCL by the 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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022


LIC809 (FAS) - (06/04)
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