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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603681
Report Date: 02/03/2025
Date Signed: 02/03/2025 04:24:25 PM

Document Has Been Signed on 02/03/2025 04:24 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALEXANDER'S HOUSE INCORPORATEDFACILITY NUMBER:
198603681
ADMINISTRATOR/
DIRECTOR:		DROUGHN, LAWRENCEFACILITY TYPE:
735
ADDRESS:1791 NAVARRO AVETELEPHONE:
(626) 298-6605
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 5CENSUS: 5DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Lawrence Droughn - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Gabriela Rivera, Direct Support Professional II (DSP II) and Alma Gutierrez, Direct Support Professional II (DSP II) and explained the purpose of the visit. At 1:30pm, Lawrence Droughn, Administrator arrived and assisted LPA. The facility is licensed to care for (4) ambulatory and (1) non ambulatory Developmentally Disabled Adults, ages 18 through 59. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door. Staff are adhering to infection control requirements. The facility has submitted the Infection Control Plan.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan was submitted to CCL and added to the Plan of Operation. Surety Bond is in effect with bond amount of $8000 and expires on 05/20/2025. Fire/Disaster Drill was last conducted on 10/28/2024.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains (3) client bedrooms, (1) bathroom, living room, kitchen, dining room, backyard, and detached garage. Currently, there are (5) clients living in the facility. Facility is a Level 4I. The interior and exterior physical plant was inspected. Client bedrooms were toured. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and observed shaded area with patio furniture. LPA also observed a lot of debris, dried leaves, fallen branches and broken fence in the backyard. Kitchen knives, sharps objects, are kept locked in a locked cabinet in the kitchen area and inaccessible to clients. LPA observed a fire extinguisher on the kitchen floor without a tag and no receipt found on file. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading in bathroom #1 was 92.1 deg F which was not within the required 105-120 degrees Fahrenheit. *****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALEXANDER'S HOUSE INCORPORATED
FACILITY NUMBER: 198603681
VISIT DATE: 02/03/2025
NARRATIVE
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Staffing: A total of (7) staff including the Administrators provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared and have training. (5) staff members listed on the roster are not associated to the facility but all (5) staff members have had their fingerprints and criminal backgrounds cleared.
Personnel Records/Staff Training: Reviewed files for (6) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Both of the Administrator's certificate expired on 07/26/2024 & 09/30/2024, but renewal was sent in July & September 2024.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are zero (0) client with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C5 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: Per the Administrator, there is no client at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Lawrence Droughn.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/03/2025 04:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/03/2025 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALEXANDER'S HOUSE INCORPORATED
FACILITY NUMBER: 198603681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in that LPA observed a fire extinguisher on the kitchen floor without a tag and no receipt found on file which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 02/04/2025
Plan of Correction
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The Licensee/Administrator will ensure that fire extinguisher in the facility is in operational condition at all times. Submit evidence of new and updated fire extinguisher, photos and copy of the receipt to show purchase date to LPA on or before POC due date.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above in that LPA observed (5) staff members' first aid/cpr certificated had expired which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 02/04/2025
Plan of Correction
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Licensee/Administrator will ensure that staff providing direct care and supervision to clients have a current first aid/CPR training. Administrator to submit a First aid/CPR training schedule for all 5 staff members by POC due date and send a copy of their certificates to CCL/LPA once completed.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/03/2025 04:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/03/2025 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALEXANDER'S HOUSE INCORPORATED
FACILITY NUMBER: 198603681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 LPA observed a lot of debris, dried leaves/branches on the ground and broken fence in the backyard which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 02/14/2025
Plan of Correction
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Administrator will send photos of the backyard/sideyard showing that it's been cleaned and the fence has been fixed to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 hot water reading in bathroom #1 was 92.1 deg F which did not meet Title 22 regulations requiremen which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 02/14/2025
Plan of Correction
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Administrator to ensure that hot water is available and maintained in the facility. Administrator to submit service report/invoice to show that the water temperature has been adjusted to CCL/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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
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