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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 04:13:38 PM


Document Has Been Signed on 03/02/2022 04:13 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Direct Care Staff, Susano ErangTIME COMPLETED:
03:30 PM
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On 2/25/2022 Licensing Program Analysts (LPA's) M. Garza and M. Thao arrived at facility to complete an unannounced Infection Control/Annual Visit. LPA's were met by Staff Susano Erang who stated Licensee/Administrator was unavailable. After many attempts LPA's spoke with Licensee and were informed she was unavailable to come to the facility. Licensee declined to have staff sign reports. LPA's were permitted into facility but not COVID pre-screened.

LPAs observed a central entry point with a supply of hand sanitizer but no sign in policy that included routine symptom screening for resident's, staff and visitors. Residents observed in bedroom off kitchen watching television.

Mitigation plan not received by CCL. Facility toured inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff observed without a face mask.

Facility has designated visitation areas. Covered trash bins in kitchen but not in bathrooms, 30 day supply of resident medications, sinks well stocked with liquid soap for hand washing and paper towels for hand drying observed. A 30 day supply of PPE not observed.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices were not found to be in compliance. Deficiencies observed during annual will be cited on a separate Case Management report.

Due to COVID precautionary measures a copy of the report will be emailed. A delivery and read receipt serves as confirmation.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
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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