197609919-11-1-2022-31-AS-ERIS-CKRTPT-20221101145453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609919
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:55:08 PM

Document Has Been Signed on 11/01/2022 02:55 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ALEXO MANOR INC		FACILITY NUMBER:	197609919
ADMINISTRATOR:	VIRAY, JEROME		FACILITY TYPE:	740
ADDRESS:	41453 ALEXO DRIVE		TELEPHONE:	(818) 332-6150
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 6	DATE:	11/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Stephanie Domingo		TIME COMPLETED:	03:00 PM

NARRATIVE

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On 11/01/2022 at 12:50 p.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at the facility mentioned above. LPA was greeted by staff #1 (S1) who granted access. Upon entrance, LPA's temperature was read and LPA was asked to sign in. Administrator, Stephanie Domingo joined us shortly after the physical tour was concluded. LPA informed Administrator of the purpose of the visit. At approximately, 1:00 p.m. a physical tour was conducted with S1 and LPA observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 03/03/2021) to make sure licensee was following current infection control recommendations. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. S1 stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen/Breakfast table: LPA toured the kitchen area and observed staff #2 (2) preparing food for residents. LPA observed non-perishable food for 7 days and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Cleaning supplies were locked in a kitchen cabinet under the sink. LPA asked S1 the name of S2 that was preparing food and helping with feeding residents. S1 stated S2's name. Administrator confirmed S2's name. LPA asked if S2's criminal background was cleared. S1 stated "Guardian status still said pending". Administrator confirmed they were still waiting for criminal background clearance.

Living Room: LPA observed living room to be clean and furniture appeared to be in good repair. A fire place was observed but not being used.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:50 p.m. they were tested and observed to be operational.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXO MANOR INC	FACILITY NUMBER: 197609919
	VISIT DATE: 11/01/2022

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Bedrooms: There are ten (10) bedrooms, six (6) of which are designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational. Four (4) out of the ten (10) bedrooms are for staff and are kept locked.

Bathrooms: LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 116.8°F. LPA observed appropriate grab bar and had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Formal Dinning area: LPA observed a large table with seating. Area was clean and clear of clutter. Dinning table and chairs appeared to be in good repair.

Laundry room: LPA observed door to laundry room locked. Chemicals and detergents are kept in laundry room locked.

Office Area: LPA observed office area clean and free of clutter.

Outdoor areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water.

Deficiency cited and Civil Penalty assessed. A Civil Penalty of $500 cited. Refer to LIC 421BG.

A copy of this report was provided/ Appeal rights provided/ Exit interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/01/2022 02:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXO MANOR INC	FACILITY NUMBER: 197609919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 2 staff not obtaining proper criminal background clearance working at the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2022
	Plan of Correction
1 2 3 4	Administrator will find a replacement and will get S2 out of the facility immediately. Administrator will ensure all staff working at this facility are cleared before starting employment.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC809 (FAS) - (06/04)

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