247200650-6-23-2022-24-AS-SMOA-CFPNYN-20220624105258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200650
Report Date: 02/25/2022
Date Signed: 06/23/2022 11:25:55 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2022 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20220120105220

FACILITY NAME:	ALEXANDER RESIDENTIAL CARE HOME		FACILITY NUMBER:	247200650
ADMINISTRATOR:	AMPARO CULLEN		FACILITY TYPE:	740
ADDRESS:	1728 E. ALEXANDER AVENUE		TELEPHONE:	(209) 383-2326
CITY:	MERCED	STATE: CA	ZIP CODE:	95340
CAPACITY:	6	CENSUS: 2	DATE:	02/25/2022
		UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Direct Care Staff, Susano Erang		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Staff do not answer the facility telephone
Staff do not keep the facility free from pests
Staff do not communicate effectively

INVESTIGATION FINDINGS:

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On 2/25/2022 Licensing Program Analysts (LPA's) M. Garza and M. Thao arrived at facility to complete a complaint visit on the above allegations. LPA's were met by Direct Care Staff, Susano Erang. 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 delivered findings to the above allegations.

Allegation: Staff do not answer the facility telephone
During investigation LPA, Ombudsman and family of residents attempted to reach facility via telephone. During these attempts the phone was not answered. LPA observed telephone in kitchen was not plugged into a phone jack and the phone stated "out of range" and "no pwr to base". This allegation is SUBSTANTIATED.

Allegation: Staff do not communicate effectively
Due to the facility not having a working phone at the time of visits the allegation is SUBSTANTIATED as the facility is unable to communicate with other agencies and responsible parties.
CONT....

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 24-AS-20220120105220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

NARRATIVE

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Allegation: Staff do not keep the facility free from pests
During the investigation RP alleged they observed roaches on the counter. LPA observed pest droppings throughout the kitchen area. LPA observed a pest trap behind the microwave with live bugs. During interviews staff alleged the facility was receiving pest control. However was unable to provide receipt verification showing pest services were being received. This allegation was SUBSTANTIATED.

The allegations listed above were SUBSTANTIATED. The following deficiencies was cited per CA Code of Regulations Title 22 – refer to the 9099D.

Exit interview completed. Appeal rights given.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20220120105220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B 03/07/2022 Section Cited CCR 87311	1 2 3 4 5 6 7	87311 Telephones All facilities shall have telephone service on the premises... This requirement was not met as evidence by: Through observation and interviews it was determined faciilty did not have a funtioning telephone. Phone was not plugged into phone jack. When called phone did not ring in facility.	1 2 3 4 5 6 7	Facility to provide updated contact information for the facility. Licensee to provide CCL a written plan to ensure facility phone is operable and available for resident use. Plan to include proof of phone service. Licensee to provide to CCL by POC date.
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Type B 03/07/2022 Section Cited CCR 87555(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidence by: Through LPAs observations and interviews a sticky trap was observed behind microwave in the kitchen with live roaches. Droppings observed throughout the kitchen.	1 2 3 4 5 6 7	Facility to provide CCL proof of pest control receipts from the last two months (Jan and Feb 2022) by POC date.
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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: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: (559) 365-9009
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

LIC9099 (FAS) - (06/04)

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