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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200118
Report Date: 06/23/2022
Date Signed: 06/23/2022 10:13:31 AM

Document Has Been Signed on 06/23/2022 10:13 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, 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:
06/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Gabriele Sibonga, AdministratorTIME COMPLETED:
10:20 AM
NARRATIVE
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On 6/23/2022 at 8:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 6/9/2022. LPA met with Administrator, Gabriele Sibonga.

Incident report dated 6/9/2022 revealed that C1 left the facility on 6/8/2022 at around 9:30AM. S2 saw C1 walking and followed C1, but lost C1 around a corner. Staff tried to look for C1, but was unsuccessful. Staff called police for assistance. C1 was found by police about 30 minutes later.

Interview with S1 revealed that C1 has a history of AWOL. S2 stated that C1 walked fast and unable to find C1. S2 called police after unsuccessful in finding C1. S2 gave police facility's contact information. Less than an hour later, C1 was found by police. S1 stated C1 had a doctor's appointment on 6/21/2022 and medications were changed. C1's case manager is aware of the situation and will approve C1 to have 1:1 care and supervision.

During record review, LPA observed that physician's report dated 3/17/2022 stated that C1 cannot leave the facility unassisted. C1's IPP (Individual Program Plan) did not indicate that C1 required 1:1 care and supervision.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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 06/23/2022 10:13 AM - It Cannot Be Edited


Created By: Grace Luk On 06/23/2022 at 09:51 AM
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: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2022
Section Cited
CCR
80068(b)

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Needs and Services Plan. If the client has an existing...individual program plan (IPP)..., the Department may consider the plan to meet the requirements... This requirement is not met as evidence by:
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Administrator has agreed to update C1's needs and service plan and submit a copy to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not having an updated needs and service plan for C1 which poses a potential health and safety risk to the persons 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


LIC809 (FAS) - (06/04)
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