247200650-8-30-2022-24-AS-SMOA-CJVK9H-20221004074219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247200650
Report Date: 08/30/2022
Date Signed: 08/30/2022 05:13:17 PM

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
05/10/2022 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20220510160330

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:	08/30/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Administrator, Amparo Cullen		TIME COMPLETED:	05:13 PM

ALLEGATION(S):

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Masks are not being worn

INVESTIGATION FINDINGS:

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On 8/30/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility unannounced to deliver findings on the complaint allegation listed above. LPA met with Licensee, Amparo Cullen. Licensee was advised the reason for the visit and permitted entry into the facility. LPA was not COVID pre-screened upon entry. A health and safety check on residents in care was completed. Residents were observed in common area and in kitchen.

During the investigation LPA requested and reviewed 2 personnel files. LPA did not observe files to have a Physician’s note exempting staff from wearing face coverings as required. Interviews disclosed RP visited facility on 5/6/22 and observed S1 without a face covering at time of visit. LPA observed S2 without a face covering on 5/17/22. S2 disclosed during an interview S1 and S2 were exempt from wearing a face covering. However, did not provide verification of this with a physician’s note or verification of religious reasons.The allegation listed above has occurred. The allegation is SUBSTANTIATED and met the preponderance of evidence standard per Title 22. Deficiencies cited on 9099D.

Exit interview completed. A copy of this report and appeal rights given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20220510160330

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: 08/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/15/2022 Section Cited CCR 87470(a)	1 2 3 4 5 6 7	87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows:...	1 2 3 4 5 6 7	Licensee to provide training to all staff on infection control regulation. A copy of training material and sign in sheet to be provided to CCL by POC date. Facility Licensee stated last 2 residents will be moving out on 9/2/22. Facility will be closing by no later than 9/15/2022. License will be turned over to CCL by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidence by LPA interviews, record review and observations. Personnel files did not reflect exemptions for staff not to wear face coverings. Interviews with RP, staff and licensee support staff was not wearing masks as required. On 5/17/22 and 8/30/22 LPA observed staff without face coverings during visits. This poses a potential health and safety or personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

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