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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601092
Report Date: 08/29/2024
Date Signed: 08/29/2024 04:01:59 PM

Document Has Been Signed on 08/29/2024 04:01 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ALEXEI'S HOMEFACILITY NUMBER:
415601092
ADMINISTRATOR/
DIRECTOR:		FLORES, VICTORIAFACILITY TYPE:
735
ADDRESS:140 OAKFIELD AVENUETELEPHONE:
(650) 307-3607
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 3CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Victoria Flores, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On August 29, 2024, Licensing Program Analysts (LPAs) Kiran Jain and John Calandra arrived at the facility at 10:30 AM to conduct the Annual 1-year required inspection. LPAs Jain and Calandra met with caregiver Rome Cajigal, caregiver and explained the purpose of the visit. Administrator/Licensee, Victoria Flores arrived at the facility later during the visit.

LPAs Jain and Calandra toured the physical plant. This is a 2-story building with 3 bedrooms, 2 bathrooms, kitchen, office, laundry room, and living room with dining on the 1st floor. 2nd floor is designated for staff with 1 room and 1 bathroom. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged and last serviced on 08/23/2020. The smoke detector and carbon monoxide detector were fully operational.

All rooms were observed to be clean with sufficient furniture and lighting. The hot water temperature in the bathroom sink faucet was measured at 122°F, which in above the required range of 105-120°F.

Sharp objects, detergents, poisons, and soap were observed to be accessible to persons in care. In the presence of the LPAs, they were locked and are no longer accessible to persons in care.

The kitchen sink water temperature was measured at 127°F. No expired food items were observed. The facility had the required 7-days of non-perishables and 2-days of perishables food items.

LPA reviewed 3 resident files and 6 staff files. All were observed to be complete.

The client’s medications were securely stored in a locked cabinet. Medication administration records (MARs) were reviewed and found to match Centrally Stored Medication Records kept at the facility. The First Aid kit was checked and found to have the required items.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/29/2024 04:01 PM - It Cannot Be Edited


Created By: Kiran Jain On 08/29/2024 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALEXEI'S HOME
FACILITY NUMBER: 415601092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 80088(e)(1) Fixtures, Furniture, Equipment, and Supplies: Based on observation the licensee did not comply with the section cited above in 2 out of 2 faucets in the bathroom and kitchen which delivered hot water temperatures above 120°F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction outlining how this violation will be avoided in the future to licensing office by the due date of 08/30/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ALEXEI'S HOME
FACILITY NUMBER: 415601092
VISIT DATE: 08/29/2024
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The following updated forms are requested to be submitted to CCLD by 09/06/2024:
    · LIC 500: Personal Report
    · LIC 999: Facility Sketch (Floor Plan)

A Type A Violation was provided for having hot water temperatures exceeding 120°F.

A Technical Violation was provided for having a door alarm that was turned off on exterior doors. Administrator/Licensee Victoria Flores turned on door alarms in the presence of the LPAs.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.
    An exit interview was conducted. This report was reviewed with Victoria Flores, Administrator/Licensee and a copy of this report along with appeal rights was left at the facility.
    SUPERVISORS NAME: April Cowan
    LICENSING EVALUATOR NAME: Kiran Jain
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 08/29/2024
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 08/29/2024
    LIC809 (FAS) - (06/04)
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