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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609919
Report Date: 05/06/2025
Date Signed: 05/06/2025 05:12:41 PM

Document Has Been Signed on 05/06/2025 05:12 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 INCFACILITY NUMBER:
197609919
ADMINISTRATOR/
DIRECTOR:		VIRAY, JEROMEFACILITY TYPE:
740
ADDRESS:41453 ALEXO DRIVETELEPHONE:
(818) 332-6150
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
05/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Rocela Molina - Lead CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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In conjunction with control number 31-AS-20250428084431 complaint visit, Licensing Program Analyst (LPA) Evelin Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. A case management report is being issued today in conjunction to the complaint visit report for observed deficiencies not related to complaint. LPA met with Rocela Molina - Lead Caregiver.

Interview with staff revealed there was a staff #1 (S1) who provided care to residents in the facility. Review of S1's record and Guardian Background Check revealed S1 is not fingerprinted cleared.

Review of five (05) out of (05) resident records revealed resident #4 (R4) had after visit paperwork from emergency room visits. According to the Lead Caregiver, R4 had medical emergencies that required the facility to contact 911 on separate occasions. Review of Community Care Licensing Division (CCLD) records revealed the facility had not submitted Unusual Incident/Injury Report to CCLD. Review of R1's record revealed the facility submitted Unusual Incident/Injury Reports from 02/05/2025 to 04/07/2025 to Long Term Care Ombudsman about R1's ongoing interactions involving certain facility staff. Review of Community Care Licensing Division (CCLD) records revealed the facility had not submitted Unusual/Injury Incident Reports to CCLD.


Deficiencies observed and cited (Refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of Report Issued.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/06/2025 05:12 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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2025
Section Cited
CCR
87355(d)(3)

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(d) All individuals subject to a criminal record review shall be fingerprinted...(3) The licensee shall submit these fingerprints to the California Department of Justice... prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
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According to the Lead Caregiver the staff is no longer working in the facility. Licensee with review the regulation cited and submit a statement of understanding to LPA by POC due date 05/07/2025.
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Based on interviews and record review the licensee did not comply with the section cited above, in one staff identified was not fingerprint cleared for the facility. This poses an immediate health, safety or personal rights risk to persons in care.
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Type B
05/16/2025
Section Cited
CCR87211(a)(1)

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(a) Each licensee shall furnish to the licensing agency... the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement is not met as evidenced by:
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Lead Caregiver provided Unusual Incidents/Injury Reports involving R1 to LPA on todays visit. Licensee will submit Unusual incident reports of R4 to LPA by POC due date 05/16/2025.
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Based on interviews and record review the licensee did not comply with the section cited above, in incidents involving R4 and R1 not reported to CCLD within seven days of occurrence which poses a potential health, safety or personal rights risk to 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.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104

DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025

LIC809 (FAS) - (06/04)
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