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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530042
Report Date: 07/25/2024
Date Signed: 07/25/2024 10:39:33 AM

Document Has Been Signed on 07/25/2024 10:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ALEXANDER CARE CENTERFACILITY NUMBER:
365530042
ADMINISTRATOR/
DIRECTOR:		LAYGO, ADRIANFACILITY TYPE:
737
ADDRESS:22370 VIA SECO STREETTELEPHONE:
(760) 381-0480
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 4CENSUS: 2DATE:
07/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Neil Clavecillas - Lead Staff TIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to follow-up on the death of client#1 (C1). LPA met with Niel Clavecillas, Lead Staff, and discussed the purpose of the visit.

During today's visit, LPA obtained copies of pertinent documents and obtained information on events leading up to C1's death. The Lead Staff stated that there is no official death certificate at this time. LPA requested a copy of C1's death certificate to be submitted to Community Care Licensing Division (CCLD) Regional office when it is available.

An exit interview was conducted where this report was discussed and a copy was provided to the Lead Staff at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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