197610027-4-22-2022-31-AS-SSTS-CDQQR3-20220422122317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610027
Report Date: 04/22/2022
Date Signed: 04/22/2022 12:23:54 PM

Document Has Been Signed on 04/22/2022 12:23 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ALLESSANDRA HOME CARE		FACILITY NUMBER:	197610027
ADMINISTRATOR:	ANDRADA, LEANDRO		FACILITY TYPE:	740
ADDRESS:	2822 ALLESSANDRA COURT		TELEPHONE:	(661) 206-7001
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	6	CENSUS: 4	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	Leandro Andrada, Administrator		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Shira Stamps met with Administrator Leandro Andrada for an unannounced one (1) year Required visit for this facility. Infection control: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the Administrator and asked all infection control questions. LPA was asked to sign-in and sanitize was available. LPA arrived at 11:08 am and was greeted by the Administrator. One (1) resident was observed in the living room visiting with a relative. One (1) resident was observed to be in the family room completing a puzzle. The rest of the residents were observed to be in their room sleeping, and/or getting ready for the day. LPA informed the Administrator of the purpose of the visit. A tour of the physical plant was conducted with Administrator at 11:15 am. The facility has five (5) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use only. Food Inspection LPA conducted tour at the kitchen around 11:15 am observed there to be sufficient stock of two day perishables and seven day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. LPA observed chemicals and cleaning supplies locked in the cabinet under the sink. At 11:16 am, medications were observed in the locked cabinet. There is one (1) fire extinguishers located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 03/11/22. CONTINUED...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALLESSANDRA HOME CARE	FACILITY NUMBER: 197610027
	VISIT DATE: 04/22/2022

NARRATIVE

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Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident.

Bathrooms
At 11:20 am LPA observed all bathrooms to have non-skid matts, grab bars, trash cans with lids, and the appropriated wash your hands signs posted. Hot water was tested at 11:24 am and measured within regulation at 120.0 °F.

Laundry
LPA observed chemicals/hazardous in the locked laundry room.

Garage
At 11:22 am, LPA observed the garage to be attached to the facility and currently being used for storage for extra food and PPE supplies.

Living and dining
LPA observed the living rooms to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detector were tested and observed to be operational at 11:31 am. LPA observed staff and residents’ files locked in a filing cabinet located in the living/family room.

Physical environment
LPA toured the outside area of the facility at 11:40 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Administrative: At 11:37am, LPA reviewed resident files and verified approval for bed rails for two (2) residents. LPA collected the Resident Roster and the LIC.500. Annual fee is current.

An exit interview was conducted, and a copy of this report and appeal rights were given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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