331881445-8-25-2023-18-AS-JSRS-CV2VL8-20230825163131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881445
Report Date: 08/25/2023
Date Signed: 08/25/2023 04:31:36 PM

Document Has Been Signed on 08/25/2023 04:31 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ALEXANDER'S ASSISTED LIVING HOME		FACILITY NUMBER:	331881445
ADMINISTRATOR:	VALENCIA, VERANIA		FACILITY TYPE:	740
ADDRESS:	2243 SUNNYSANDS DR		TELEPHONE:	(951) 418-9333
CITY:	PERRIS	STATE: CA	ZIP CODE:	92570
CAPACITY:	6	CENSUS: 0	DATE:	08/25/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Verania Valencia, Administrator		TIME COMPLETED:	04:25 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 08/25/2023 Licensing Program Analyst (LPA), Jacqueline Shaw Ross, conducted an announced pre-licensing inspection at the facility. The LPA met with Licensee, Verania Valencia. The application is for a Residential Care Facility for the Elderly (RCFE) for six (6) ambulatory residents. A tour was conducted of the interior and exterior of the facility. The house is a single story with, four (4) bedrooms, three (3) full bathrooms, kitchen, dining area, living room, laundry room, front/backyard area. The outdoor space is suitable for resident use and was observed to be fully fenced with an unlocked gate. The facility has taken extra security measures with security cameras in the front and back of outside areas as well as an indoor camera in the living room. The walkways of the home were observed to be clutter free with no obstructions present. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, shower and tubs have grab bars and non-skid mats. The hot water was tested in one resident bathroom and measured at 115.5 degrees Fahrenheit. Indoor temperature is 70 degrees. Night lights were observed throughout the hallways. LPA observed food storage and preparation areas and were observed to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. The kitchen was observed to have dishes, silverware and pots and pans in good repair and enough for the capacity. All appliances are clean and are operable. There is a sufficient supply of linens, towels and personal hygiene items. There is a new first aid kit; all items were present. CONTINUE ON LIC809-C...

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ALEXANDER'S ASSISTED LIVING HOME	FACILITY NUMBER: 331881445
	VISIT DATE: 08/25/2023

NARRATIVE

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CONTINUED FROM LIC809...

Licensee will have magazines, newspapers, games and other activities available for residents leisure.

LPA observed two (2) fully charged fire extinguishers. The smoke alarms and carbon monoxide detectors are all connected were tested and are operable. Medications will be stored and locked in a corner cabinet in the kitchen area. All hazardous materials such as cleaning and disinfecting supplies, knives, and other sharps are locked and inaccessible to residents. All required forms such as: emergency disaster plan and complaint poster, Administrator Certificate, personal rights, etc. are posted throughout the entrance area, dining and living room areas. LPA observed and tested a washing machine and dryer located in a locked area inaccessible to residents. The garage contained an appropriate supply of emergency food and additional cleaning supplies which are also inaccessible to residents.

Pre-licensing inspection is complete. COMP III was completed prior to the inspection on August 9, 2023. The facility is ready to be licensed.

An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee, Verania Valencia.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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