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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001396
Report Date: 11/21/2024
Date Signed: 11/21/2024 06:16:13 PM

Document Has Been Signed on 11/21/2024 06:16 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ALEXA'S HOMEFACILITY NUMBER:
306001396
ADMINISTRATOR/
DIRECTOR:		PATRICIA FESTINFACILITY TYPE:
735
ADDRESS:3117 W. CUBBONTELEPHONE:
(657) 245-3165
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 6CENSUS: 3DATE:
11/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Patricia FestinTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20241119085903.

During the complaint investigation mentioned above, it was discovered and confirmed by Staff 1 (S1) that a 30-day notice was given regarding the intent to close the facility. In the notice provided to the department it stated. “… I want to let you know that I am removing the current administrator, [Staff 2 (S2)], effective 11/05/2024 and will be replacing the administrator and staff through the relocation period.”

During the visit made to investigate complaint control # 22-AS-20241119085903, it was discovered S2 has not been removed from the facility and is still operating in the same role.

As a result of today’s Case Management visit, deficiencies will be cited for false information being provided to the department.

An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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Document Has Been Signed on 11/21/2024 06:16 PM - It Cannot Be Edited


Created By: Jerome Haley On 11/21/2024 at 05:44 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ALEXA'S HOME
FACILITY NUMBER: 306001396

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2024
Section Cited
HSC
1550(c)

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1550 Licenses or administrator Certificates; suspension, revocation or denial of application; grounds

The department may deny an application for, or suspend or revoke, any license, or any special permit, certificate of approval, or administrator certificate, issued under this chapter upon any of the following grounds and in the manner provided in this chapter, or may deny a transfer of a license pursuant to paragraph (2) of subdivision (b) of Section 1524 for any of the following grounds: (c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.
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The Administrator will read and review the entire regulation section 1550 Licenses or administrator Certificates; suspension, revocation or denial of application; grounds and send a statement of acknowledgment and understanding to LPA Haley by the POC due date of Monday, November 25, 2024 at 4:00pm.
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This requirement was not met as evidenced by:
During the complaint visit, Staff 2 (S2) was observed to be still working in the facility in the same capacity and was never removed as stated in the letter sent to the department.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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