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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 03:21:14 PM

Document Has Been Signed on 08/29/2024 03:21 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Victoria Flores, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On August 29, 2024, Licensing Program Analysts(LPAs) John Calandra and Kiran Jain arrived at the facility at 10:15 AM to conduct a Case Management Visit in response to a situation reported to Licensing that occurred in which a client was able to leave the facility unassisted on August 22, 2024. LPAs Calandra and Jain were greeted by Rome Cajigal, Direct Support Professionals(DSP) and explained the purpose of the visit. Victoria Flores, Licensee/Administrator arrived later during the visit.

While talking to the Administrator/Licensee, Victoria Flores, R1 left the facility unassisted. R1 has a history of AWOL and per review of R1's LIC 602: resident is not able to leave facility unassisted. R1 had previously also run out of the home and staff ran after resident but could not locate resident for a few minutes. Per resident record review, R2 is also unable to leave facility unassisted.

A Type B Violation was provided for not ensuring basic services were being met. R2 has a history of leaving the facility unassisted. Due to lack of supervision, R2 was able to leave the facility unassisted.

Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted. This report was reviewed with Victoria Flores, Administrator/Licensee and a copy of the report left at the facility along with Appeal Rights.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
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)
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Document Has Been Signed on 08/29/2024 03:21 PM - It Cannot Be Edited


Created By: John Calandra On 08/29/2024 at 12:06 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited
CCR
80065(a)

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80065(a): Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
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Facility administrator will submit a plan to LPA regarding how facility will ensure R1's needs are met. For ex: if assigned caregiver takes a break, how will facility ensure R1's needs and services are met.
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Based on the file reviewed and interviews conducted, the facility did not ensure basic services were being met. In addition, it was indicated that R2 has a history of AWOL. Due to lack of supervision, R2 AWOL.
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
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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