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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530042
Report Date: 11/18/2022
Date Signed: 11/18/2022 03:25:21 PM

Document Has Been Signed on 11/18/2022 03:25 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, 744 P STREET, MS 9-14-8201
, CA 95814
FACILITY NAME:ALEXANDER CARE CENTERFACILITY NUMBER:
365530042
ADMINISTRATOR:LAYGO, ANITAFACILITY TYPE:
737
ADDRESS:22370 VIA SECO STREETTELEPHONE:
(951) 347-0985
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: DATE:
11/18/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Adrian Laygo TIME COMPLETED:
03:20 PM
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Component II completion: Successful

Facility Type: ARF-EBSH
Application Type: Initial
Capacity: 4
Census (if any clients in care): 0
COMP II Participants: Adrian Laygo (applicant/licensee, administrator)
Interview Method: Telephone interview


On 11/18/22, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements/CPMB associations & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Tracy Thompson
LICENSING EVALUATOR NAME: Susan Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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