306004099-9-3-2024-28-AS-EZAA-D8RP3R-20240903105758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004099
Report Date: 09/03/2024
Date Signed: 09/03/2024 10:58:39 AM

Document Has Been Signed on 09/03/2024 10:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ALEXANDER FAMILY HOME		FACILITY NUMBER:	306004099
ADMINISTRATOR/ DIRECTOR:	HILEWNA TAMRAT		FACILITY TYPE:	735
ADDRESS:	13020 BONA VISTA LANE		TELEPHONE:	(562) 404-9673
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 4		CENSUS: 4	DATE:	09/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:01 AM
MET WITH:	Bianca Alexander - Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Bianca Alexander, Assistant Administrator for the facility, and explained the purpose of the visit. There are four (4) ambulatory clients residing in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has a completed infection control plan.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) ambulatory clients between the ages of eighteen (18) through fifty-nine (59). It consists of three (3) client bedrooms, a kitchen/dining room, a living room, an office, a staff restroom, and a client restroom which had a hot water temperature reading of 110.6 Degrees Fahrenheit. Knives along with the chemicals and cleaning supplies are kept locked and inaccessible to clients. A shaded outdoor area was available for clients in the backyard of the facility.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools are or bodies of water accessible to the clients. Fire alarm system is operational. The facility has two (2) fully charged fire extinguishers that are kept in the facility.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 09/03/2024 10:58 AM - It Cannot Be Edited

Created By: Erik Zaragoza On 09/03/2024 at 10:45 AM

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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALEXANDER FAMILY HOME	FACILITY NUMBER: 306004099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85165(h)(1)

Emergency Intervention Staff Training

(h) The licensee shall maintain a written record of the staff training. (1) Documentation of the training received by each staff member shall be maintained in the personnel records, pursuant to Section 80066, and include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff members, because one staff member had an expired CPI card in their records, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Licensee is to ensure that all staff members have current CPI cards in their records at all times. Licensee/Administrator is to obtain an updated CPI card for the identified staff member and email LPA proof of the staff member's updated CPI card by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

David Sicairos

LICENSING EVALUATOR NAME:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALEXANDER FAMILY HOME	FACILITY NUMBER: 306004099
	VISIT DATE: 09/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Cleaning supplies and toxic substances are kept locked and inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.

Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) ambulatory clients between the ages of 18 – 59.

· Care and supervision to meet the clients’ needs was observed.

Staffing:

· A total of nine (9) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate expires in June of 2026.

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.
· One (1) out of five (5) staff files reviewed did not have a current Crisis Prevention Intervention (CPI) card on record.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALEXANDER FAMILY HOME	FACILITY NUMBER: 306004099
	VISIT DATE: 09/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.

· None of the clients of the facility have a restricted health condition or restricted health care plan.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Four (4) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.
Incidental Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D is kept in the facility.

· The last documented disaster drill was documented in August of 2024.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4