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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610027
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:09:42 PM


Document Has Been Signed on 06/14/2023 03:09 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 CAREFACILITY NUMBER:
197610027
ADMINISTRATOR:ANDRADA, LEANDROFACILITY TYPE:
740
ADDRESS:2822 ALLESSANDRA COURTTELEPHONE:
(661) 206-7001
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 5DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Leandro Andrada, AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Shira Stamps arrived at 10:05 am and met with the Administrator Leandro Andrada. Entrance interview conducted.

LPA and the Administrator conducted a tour of the facility at 10:18 am. The following was observed:

LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council.

Common Areas: LPA toured all common areas of the facility. LPA observed common areas to be clean and furniture to be in good repair. The facility maintains a comfortable temperature at 75 degrees F. LPA observed fire extinguisher to be full and last serviced on 3/13/23. At 10:35am, LPA tested and verified all the carbon monoxide and smoke detectors were operational. LPA observed the first aid kits located in the locked hallway closet, but did not observe the first aid Manual.

Resident rooms: LPA observed rooms to have appropriate bedding sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, night stand and sufficient lighting for each resident. LPA tested the door alarm system and it was observed to be operational. LPA observed in room # 1 prescribed topical powder located beside resident #1 (R1’s ) bed. LPA reviewed R1’s physician report (Dated: 2/14/23) and it was found that R1 is not able to administer prescription medications. The Administrator placed it in the locked medication cabinet. LPA observed bed rails in Room #1,4. LPA reviewed resident files and found prescriptions for each individual with bed rails.

Bathrooms: At 10:10 am LPA observed the bathrooms to have non-skid matts, grab bars, and wash your hands signs posted. Residents have sufficient amounts of supplies for personal hygiene which is provided by the Licensee. At 10:40am hot water measured with in regulation of 105 degrees F and 120 degree F.
CONTINUED...
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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 06/14/2023 03:09 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ALLESSANDRA HOME CARE
FACILITY NUMBER: 197610027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there was no current edition of a first aid manual approved by the American Red Cross which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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The Administrator will purchase a edition of a first aid manual approved by the American Red Cross by the POC due date, and provide the LPA a picture of the receipt.
Type B
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that a prescribe topical powder was located in room #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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The Administrator will conduct training regarding the regulation section cited above. Training material and signatures of all staff members who attended the training will be provided to the LPA by the 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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 06/14/2023
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Laundry service: There is enough linen available to change weekly or more if need.

Outside areas: LPA toured the outside area of the facility at 10:33am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed no bodies of water on the premises.

Food Inspection: LPA conducted a food inspection tour at 10:20 am. LPA observed there to be sufficient stock of two- perishable and seven-day non-perishables foods. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

Laundry/Garage: LPA observed the laundry room to be locked. Chemicals and laundry detergent are stored in the laundry room. To access the garage you have to go through the locked laundry room. The garage attached to the facility and currently being used for storage and there is an extra refrigerator and freezer.



Personnel Records: LPA reviewed 10 staff records. Staff are fingerprint cleared. LPA observed the Administrator certificate to be valid until 09-24-2019. All 10 staff have current first aid. Some staff have current CPR.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500. Annual fee is current.

Deficiencies were issued per CA code of Regulations Title 22 or Health and Safety Code. See 809D's included with this report.



Appeal rights issued.Exit interview conducted. Copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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