197609919-11-13-2023-31-AS-ERIS-CXJVVV-20231113154657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609919
Report Date: 11/13/2023
Date Signed: 11/13/2023 03:47:09 PM

Document Has Been Signed on 11/13/2023 03:47 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:	11/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Stephanie Joy P. Domingo - Administrator		TIME COMPLETED:	04:00 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 11/13/2023 at 9:55 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 required postings on the entry and hallway wall. S1 contacted the administrator. LPA informed Administrator of the purpose of the visit. Administrator, Stephanie Domingo joined us shortly after the physical tour was concluded. At approximately, 10:00 a.m. a physical tour was conducted with S1 and LPA observed the following: 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 and sit the capacity of the facility. Kitchen/Breakfast table: LPA toured the kitchen area and observed staff #2 (2) preparing food 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. Cleaning supplies were locked in a kitchen cabinet under the sink. LPA observed a fire extinguisher fully charged. Living Room: LPA observed the living room to be clean and furniture appeared to be in good repair. A fire place was observed and not in use, secured with a screen. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:26 a.m. they were tested and observed to be operational. LPA observed fire doors and fire sprinklers. 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. Four (4) out of the ten (10) bedrooms are for staff and are kept locked. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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 11/13/2023 03:47 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: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in three (3) residents with Dementia (resident #1 (R1), resident #2(R2) and resident #4 (R4)) by not conducting medical assessments annually which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	Administrator will schedule R1, R2 and R4 for a medical assessment and conduct reappraisals. Administrator will email a copy of each residents' physician's report and reappraisals to LPA by POC due date.

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: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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: 11/13/2023

NARRATIVE

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(Continued from LIC809)
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 papers, soap and paper towels. LPA observed appropriate grab bars, non-skid mats, and trash cans with fitted lids to protect from cross contamination. The hot water temperature was taken at 10:30 a.m. and measured at 120°F. Auditory alarms were tested and observed to be operational.

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

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 storing furniture and other facility items. LPA also observed a hobby farm; facility is growing their own vegetables.

Resident and Staff Files: Resident and staff files are maintained locked in a hallway walk-in closet. LPA conducted a file review of resident records to insure compliance of licensing forms from 10:45 a.m. to 12:33 p.m. Review of residents with special health needs records revealed three (3) residents with dementia (resident #1 (R1), resident #2(R2) and resident #4 (R4)) did not have an annual medical assessment done. LPA also conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing forms at 12:34 p.m.

Medications: Medication and Medication Records are stored in a locked hallway walk-in closet. Medications were reviewed for proper storage and documentation at 1:09 p.m. Facility also uses a Medication Administration Record (MAR).

LPA conducted resident and staff interviews at 3:11 p.m.

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: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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