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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881445
Report Date: 09/13/2024
Date Signed: 09/13/2024 01:34:26 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/13/2024 01:34 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ALEXANDER'S ASSISTED LIVING HOMEFACILITY NUMBER:
331881445
ADMINISTRATOR:VALENCIA, VERANIAFACILITY TYPE:
740
ADDRESS:2243 SUNNYSANDS DRTELEPHONE:
(951) 418-9333
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY:6CENSUS: 0DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Verania ValenciaTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Verania Valencia who was informed of the purpose of the visit. The facility has no current residents in care, and has not had residents in care since being licensed.

The facility is a one story home with (4) bedrooms and (2) bathrooms. No pools or firearms are being kept at the facility.

Physical plant, floors, and base boards were observed. The facility has a break in a water pipe which caused the flooring and wood cabinetry to be removed. The fixtures and furniture and appliance were observed in a storage unit on the property and in the backyard. LPA observed there are no current residents in care. The licensee stated the break happened (2) weeks ago. Repairs to flooring, bathrooms, kitchen, plumbing, and reintegration of furniture and supplies will be conducted by the licensee. The licensee estimates this will take (2) months to fully repair and acknowledged the need to keep the department informed of the process and any changes in the future. There are currently no staff working at the facility, and the licensee acknowledged the need to associate and fingerprint staff when hiring them to work at the facility. The licensee stated they would be paying their annual fees by September 18, 2024. The contact information, mailing address, phone numbers and email address was reviewed with the licensee for accuracy. Deficiency was cited for the licensee not informing the department of changes to the plan of operation, and repairs and renovations to the home which makes it unable to house residents in a safe manner.



An exit interview was conducted where this report, appeal rights, and deficiency page was reviewed and provided. A collaborative plan of correction was created and documented.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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 09/13/2024 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ALEXANDER'S ASSISTED LIVING HOME
FACILITY NUMBER: 331881445

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2024
Section Cited
CCR
87208(a)(7)

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(a)....Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (7) Sketches, showing dimensions...
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The licensee agreed to send the LPA a statement of acknowledgment of understanding the section cited and cooperation in informing the department of repairs and completion. This is due by the POC due date.
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Based on observation and interview, the licensee did not contact the department on changed to the physical plant and renovations needed to the physical plant. This poses a potential risk personal rights, health or safety risk.
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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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