197609919-12-3-2024-31-AS-ERIS-DBLUYY-20241203150042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609919
Report Date: 12/03/2024
Date Signed: 12/03/2024 03:01:18 PM

Document Has Been Signed on 12/03/2024 03:01 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/ DIRECTOR:	VIRAY, JEROME		FACILITY TYPE:	740
ADDRESS:	41453 ALEXO DRIVE		TELEPHONE:	(818) 332-6150
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Stephanie Domingo - Administrator Designee		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE
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	On 12/03/2024 at 9:15 a.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. LPA observed appropriate postings on the entry and hallway wall. Staff #2 (S2) contacted the administrator. Administrator Designee, Stephanie Domingo met with LPA at the facility. LPA informed Stephanie of the purpose of the visit. At approximately, 9:20 a.m. a physical tour was conducted and LPA observed the following: 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 and sit the capacity of the facility. Bedrooms: LPA observed, six (6) resident bedrooms with sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. LPA observed over the counter medication on resident #4's (R4's) bedside table in bedroom #4. Stephanie removed it immediately. Review of R4's Physician's Report revealed they are not able to store own medications. LPA and Stephanie discussed the facility sketch and the approved fire inspection from 2019. LPA obtained a copy of current facility sketch with approved stamp from City of Lancaster Building and Safety for garage conversion. Administrator will submit an LIC 200 indicating caregiver bedroom from facility sketch in 2019 has been changed to resident bedroom #5. Bedroom #5 is currently vacant. Bathrooms: LPA observed three (3) bathrooms one (1) is located in a residents private bedroom. All bathrooms were clean and in good repair. Properly supplied with toilet paper, soap and paper towels. LPA observed appropriate grab bars, non-skid mats, and trash cans with fitted lids, to protect from cross contamination. (Continued on LIC809-C)

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: 12/03/2024

NARRATIVE

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 LIC809) The hot water temperature was taken from two (2) shared bathroom at approximately 10:26 a.m. and measured between 111.9°F and 114.3 120°F, within regulation..

Kitchen: LPA toured the kitchen area and observed S2 preparing breakfast for residents. LPA observed a 7 day non-perishable and 2 day perishable supply of food; properly stored. All knives and sharps were observed locked in a kitchen cabinet and inaccessible to residents. LPA observed a fire extinguisher fully charged with service date 11/14/2024. LPA observed four (4) telephones in the facility accessible to residents.
Outdoor Area: 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. LPA observed a small shed used for storage. LPA also observed a vegetable garden.
Living Room: LPA observed the living room to be clean and furniture appeared to be in good repair. A fire place was observed, secured with a screen. Smoke detectors were located throughout the facility, and were tested at 10:32 a.m., they were observed to be operational. LPA observed a carbon monoxide detector that appeared operational. Facility is also equipped with two fire doors and fire sprinklers.
Laundry Room: LPA observed door to laundry room locked. Cleaning supplies such as chemicals and detergents are kept locked in the laundry room.
Resident and Staff Files: Resident and staff files are maintained locked in a hallway walk-in closet. From 11:12 a.m. to 1:10 p.m., LPA conducted a file review of five (5) resident records to insure compliance of licensing forms and also conducted a file review of three (3) staff records to insure forms and training are up to date. Review of R4's admission agreement revealed, R4's representative and Licensee's representative signatures and dates were missing. Two (2) staff records did not have active 1st Aid and CPR certification on file. LPA reviewed liability insurance, infection control and LIC500.
Medications: Medication and Medication Records are stored in a locked hallway walk-in closet. Medications were reviewed for proper storage and documentation at 2:12 p.m. Facility also uses a Medication Administration Record (MAR).

Deficiency cited, refer to LIC809-D. Exit interview conducted. A copy of this report was provided. Appeal rights provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/03/2024 03:01 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above where LPA observed over the counter medication in resident #4's (R4's) bedside table and the facility has residents diagnosed with Dementia, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/04/2024
	Plan of Correction
1 2 3 4	Administrator Designee removed medication immediately. Administrator will conduct in-service training with all staff regarding the regulation cited and send LPA a copy of sign-in sheet of staff that participated in training.

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.

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/03/2024 03:01 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two (2) out of three (3) staff not having current 1st aid and CPR on file at time of visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	Administrator agrees to submit copies of staff 1st aid and CPR certification to LPA by POC due date.

Section Cited

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one(1) out of five (5) residents admission agreements which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	Administrator agrees to submit a copy of R4's completed admission agreement to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4