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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004099
Report Date: 10/03/2025
Date Signed: 10/03/2025 03:28:42 PM

Document Has Been Signed on 10/03/2025 03:28 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALEXANDER FAMILY HOMEFACILITY NUMBER:
306004099
ADMINISTRATOR/
DIRECTOR:		HILEWNA TAMRATFACILITY TYPE:
735
ADDRESS:13020 BONA VISTA LANETELEPHONE:
(562) 404-9673
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 3DATE:
10/03/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:29 PM
MET WITH:Maryjane Valles - DSPTIME VISIT/
INSPECTION COMPLETED:
03:43 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced case management visit to follow up on deficiencies identified on a Semi-Annual Residential Review Conducted by the East Los Angeles Regional Center (ELARC) dated 7/14/2025. LPA met with Maryjane Valles, Direct Support Staff for the facility, and explained the purpose of the visit. Licensee Yvonne Paredes-Alexander was notified of the visit by phone call.

The Semi-Annual Residential Review conducted by ELARC identified three (3) deficiencies in the report: that the facility had expired deli meat in the refrigerator, that the meal menu didn't specify the date in which it was developed, and that there were missing staff initials in the Medication Administration Record (MAR) for Client #1 (C1) for one of their bedtime medications on 7/2/2025.

During review of the medications, LPA observed that there were no errors in medication administration or documentation in the MAR. During review of the refrigerator, LPA observed that there were no spoiled meats, that all meats were labeled clearly with their expiration dates, and that the refrigerator has a log which documents when it is checked for spoilage. During review of the facility meal menu, LPA observed that it was dated on August 2025, however per Title 22 regulation it is required that it is developed at least one (1) week in advance.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed are recorded on the LIC809D pages. Exit interview was held and a copy of the report will be provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/03/2025 03:28 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 10/03/2025 at 03:02 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
, 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: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2025
Section Cited
CCR
80076(a)(5)

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(a) In facilities providing meals to clients, the following shall apply: (5) Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the (...) licensing agency upon request.
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Administrator is to ensure that meal menus are developed at least one week in advance for the clients in the facility. Administrator is to develop a meal menu for the month of October and email the menu to the LPA along with facility's plan to meet the regulation by the POC due date.
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This regulation is not met as evidenced by: Based on record review, the licensee did not comply with the section in 3 out of 3 clients, as the current meal menu is dated for the month of August 2025, which poses a potential health and safety concern to clients in care.
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Type B
10/24/2025
Section Cited
CCR80076(a)(7)

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(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be (...) selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption.
This regulation is not met as evidenced by:
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**POC Cleared** Administrator is to ensure that food is kept free from spoilage at all times. Administrator is develop a plan that prevents food spoilag in the refrigerator and send it to the LPA by the POC due date.
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This regulation is not met as evidenced by: Based on a report from ELARC, it was determined that there was spoiled meats found in the refrigerator of the facility, which poses a potential health and safety risk to clients in care.
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/03/2025 03:28 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 10/03/2025 at 03:20 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
, 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: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2025
Section Cited
CCR
80070(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This regulation is not met as evidenced by:
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Administrator is to ensure that all clients MARs are completely and accurately documented when their medications are administered at all times. Administrator is to email the facility's plan for how they will ensure documentation is completed fully and accurately by the POC due date.
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Based on a report from ELARC, it was determined on 7/2/2025 there were missing staff initials on the MAR for once client's bedtime medications, which poses a potential health and safety risk for the clients in care.
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
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