<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880904
Report Date: 05/23/2022
Date Signed: 05/23/2022 02:42:07 PM

Document Has Been Signed on 05/23/2022 02:42 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALEXANDRIA BOARD AND CARE, INCFACILITY NUMBER:
331880904
ADMINISTRATOR:ABDOU, HANYFACILITY TYPE:
735
ADDRESS:27226 WEDGEWOOD WAYTELEPHONE:
(951) 746-3780
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 4CENSUS: 4DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lead Staff Sameh MichaelTIME COMPLETED:
02:45 PM
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
On 05/23/2022, Licensing Program Analyst (LPA), Venus Mixson made an unannounced visit to conduct the required annual inspection. LPA Mixson was greeted and granted entry by caregiver Sameh Michael. LPA Mixson introduced self and explained the purpose of the visit with an emphasis on infection control. Administrator Hany Abdou arrived and gave LPA Mixson a tour of the facility.

Present in the facility were 4 clients and 1 caregiver. There are currently no cases of COVID-19 within the facility.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings. Administrator shared that they have not had the staff fit tested for the N95 mask. A Technical Advisory (TA) was provided to further explain the process.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. LPA Mixson later discussed infection control practices and procedures with Administrator.

An exit interview conducted, copy of the report, along with the LIC 811 and LIC 9102 was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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 1