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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247200650
Report Date: 02/25/2022
Date Signed: 03/02/2022 04:38:17 PM


Document Has Been Signed on 03/02/2022 04:38 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:ALEXANDER RESIDENTIAL CARE HOMEFACILITY NUMBER:
247200650
ADMINISTRATOR:AMPARO CULLENFACILITY TYPE:
740
ADDRESS:1728 E. ALEXANDER AVENUETELEPHONE:
(209) 383-2326
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:6CENSUS: 2DATE:
02/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Susano Erang, CaregiverTIME COMPLETED:
03:30 PM
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On 2/25/22 at 10:10 AM, Licensing Program Analysts (LPAs) Malia Thao and Mary Garza arrived unannounced to conduct a case management - deficiencies inspection. LPAs explained reason for inspection and was granted entry. Licensee/Administrator (LIC) Amparo Cullen was unavailable for inspection and declined staff to sign report for LIC.

During the annual inspection conducted on this day, LPAs observed the following deficiencies:

1. Front door observed with double cylinder deadbolt that uses a key to unlock from the inside, installed in door. LPA Mary Garza heard keys being used to unlock front door and heard the deadbolt unlock immediately after hearing the keys at time of entry. Keys were observed left in deadbolt lock after entry. Smoke detectors in 4 out of 4 bedrooms and hallway observed inoperable. Carbon monoxide detector observed unplugged, inoperable, and set on the floor in living room by bathroom.

2. Two scissors observed accessible in dish rack. One knife observed accessible in dish rack in kitchen sink. Two knives observed accessible in a plastic cup in cupboard. Disinfectants and cleaners observed accessible on front entry screening table, behind garage door, and in cabinets under kitchen sink and hall bathroom sinks. Garden tools (one rake, one shovel, and one hand transplanter) observed accessible in backyard.
3. Centrally stored medication cabinet observed unlocked and accessible.

4. Hot water in hall bathroom measured at 97.4 degrees F.

5. Food in kitchen and garage refrigerator freezers observed with frostbite. Foul odor observed inside garage refrigerator when opened and various perishable food items observed with mold actively growing.

Continue on LIC809-C.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ALEXANDER RESIDENTIAL CARE HOME
FACILITY NUMBER: 247200650
VISIT DATE: 02/25/2022
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Continue on LIC809.

6. Excess clothing and miscellaneous belongings observed in bedrooms #3 and 4, front hall closet, laundry room, dining room, garage, and bedroom #1 bathroom. Both refrigerators in kitchen and garage observed unclean inside and outside of refrigerators with doors and shelves covered in food stains and food debris. Kitchen counters, under kitchen counter overhang, and cabinets observed with insect droppings. Hall bathroom vanity cabinet doors observed broken and hanging by top hinge. Hall bathroom shower floor and drain observed with brown stains. Excess miscellaneous debris (Pallet with nail tips protruding out from wood, lawn chair with pot of plant on seat, 6 ft ladder, empty unused city waste blue bin, one rack, one shovel, and rusted utility dolly) observed in fire exit passageway next to garage, blocking portions of walkway. Backyard observed with excess amount of miscellaneous debris in left passageway on side of facility and behind the shed.

Deficiencies are being cited based on LPAs' observations, interviews, and records review in accordance with the California Code of Regulations, Title 22, see LIC809D.


Due to time constraints, the remaining deficiencies may be warranted at a later date. Follow up visit may be conducted or meeting to be held at Fresno Regional Office.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report will be emailed with "Read receipt" to confirm receipt of this report to Licensee's email on record.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/02/2022 04:38 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ALEXANDER RESIDENTIAL CARE HOME
FACILITY NUMBER: 247200650

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2022
Section Cited

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
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Front door observed with double cylinder deadbolt that uses a key to unlock from the inside, installed in door. LPA Mary Garza heard keys being used to unlock front door and heard the deadbolt unlock immediately after hearing the keys at time of entry. Keys were observed left in deadbolt lock after entry. Smoke detectors in 4 out of 4 bedrooms and hallway observed inoperable. Carbon monoxide detector observed unplugged, inoperable, and set on the floor in living room by bathroom. This poses an immediate safety risk to residents in care.
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Type A
02/26/2022
Section Cited

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Two scissors observed accessible in dish rack. One knife observed accessible in dish rack in kitchen sink. Two knives observed accessible in a plastic cup in cupboard. Disinfectants and cleaners observed accessible on front entry screening table, behind garage door, and in cabinets under kitchen sink and hall bathroom sinks. Garden tools (one rake, one shovel, and one hand transplanter) observed accessible in backyard. This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/02/2022 04:38 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ALEXANDER RESIDENTIAL CARE HOME
FACILITY NUMBER: 247200650

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2022
Section Cited

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...

This requirement is not met as evidenced by:
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Centrally stored medication cabinet observed unlocked and accessible. This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4