392701566-1-9-2026-27-AS-KLES-DQ6RRK-20260109121516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701566
Report Date: 01/09/2026
Date Signed: 01/09/2026 12:15:26 PM

Document Has Been Signed on 01/09/2026 12:15 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ALEXA HOME		FACILITY NUMBER:	392701566
ADMINISTRATOR/ DIRECTOR:	DAVIS, ARVIN		FACILITY TYPE:	740
ADDRESS:	2502 ALEXA WAY		TELEPHONE:	(530) 662-6055
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY: 6		CENSUS: 5	DATE:	01/09/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:30 AM
MET WITH:	Arvin Davis		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	Licensing Program Manager(LPM) Liza King and Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility to conduct a Prelicensing inspection on Alexa Home. LPM met with caregiver who contacted the Administrator, who arrived at 9:30. Ast Admin arrived at 8:30am. The purpose of the visit was explained. Current census is 5 residents, 0 are receiving hospice, 4of5 are receiving home health care, 4of5 are insulin dependent with a sliding scale. LPM verified staff present are fingerprint cleared. LPM toured the facility which included a staff room with 2 sets on bunk beds, and 4 resident rooms. The exterior of the building shows one screen which needs to be replaced and overgrown grass (given the recent rains this is not a concern). The interior living area is clean. Bathroom 1 needs the splashgaurd in the shower repaired, bathroom 2 has pink mold growing in the shower. The bathroom has the necessary DME. Water temp in bathroom measured at 105degrees, 145 degrees in the kitchen. Signage should be posted. Facility has required linen, lighting and furniture. Facility appeared clean and well kept. The facility has the necessary food, however the proper labeling of food once opened is not being completed. Breakfast consisted on a ham and cheese omelet, pancakes and sausages. First Aide kit medications expired - needs to be updated. Smoke detector beeping throughout visit. All sharps and medications were locked an inaccessible to residents. cont.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Kesha Lewis
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALEXA HOME	FACILITY NUMBER: 392701566
	VISIT DATE: 01/09/2026

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The following were unavailable for review during the prelicensing inspection, a follow up visit will occur.
The Plan of Operation was not available to review with the licensee specifically related to procedures observed in the home. Additionally the licensee did not have the emergency or evacuation procedures available to review.
Admissions agreement was not present to review during inspection nor an updated LIC500.
A request for proof of liability insurance was requested and the LPM learned insurance has been cancelled due to citations per Admin, licensee will provide proof of payment.

Current licensed facility requires bedridden clearance for 1 person and exceptions to be submitted to the department for individuals receiving insulin injections.

An exit interview was conducted a follow up visit will occur within 30 days.

Citations are issued with Plan of Correction dates on the current licensed facility.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Kesha Lewis
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026

LIC809 (FAS) - (06/04)

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