Alexo Manor

Type of visit: Required - 1 Year

On 12/15/2025 at 10:20 a.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at the facility mentioned above. LPA was greeted by Staff #1 (S1) who granted access. LPA observed appropriate postings on the walls. LPA observed Staff #2 (S2) sweeping. S1 contacted the Administrator, Richard Garcia. LPA met with the administrator and explained the purpose of the visit. At approximately, 10:30 a.m. LPA Rios initiated the physical plant tour of the facility inside and out. The following was observed: Bedrooms: LPA inspected six (6) resident bedrooms. LPA observed bedrooms to be properly furnished with a bed, mattress, night stand, drawers and have sufficient storage. The rooms were clean and free of foul odors. Bathrooms: LPA inspected three (3) bathrooms, one (1) of which is located in a resident's private bedroom. All bathrooms were clean and in good repair. Bathrooms were properly supplied with toilet paper, soap and paper towels. LPA observed appropriate grab bars, and non-skid mats. LPA measured hot water temperatures in two common bathrooms. At 2:08 p.m., the bathroom near bedroom #4 measured 115.9°F. At 2:09 p.m., the bathroom near bedroom #2 measured 117.0°F. Laundry Room: By bedroom labeled #1, LPA observed a locked door to the laundry room. LPA observed a washer and dryer and cleaning supplies such as chemicals and detergents. (Continued on LIC809-C) (Continued from LIC809)Facility is equipped with two fire doors, fire sprinklers, and smoke detectors throughout. At 11:04 a.m., the administrator tested the smoke detectors and they were observed operational. LPA also observed more than one functioning carbon monoxide detector. Common Areas: The common areas such as the dining areas and living room were clean and clear of clutter. Tables and chairs appeared to be in good repair and sit the capacity of the facility. In the living room the couches and recliners were observed to be clean and in good repair. No tripping hazards observed. Doors in bedrooms and common areas leading to the outside have auditory alarms that were on and working properly. Kitchen: LPA inspected the kitchen and observed a 7 day non-perishable and 2 day perishable supply of food. All knives and sharps were observed locked in a kitchen cabinet and inaccessible to residents. LPA observed a fire extinguisher fully charged with service date 11/10/2025. LPA observed telephones through out the facility accessible to residents. Outdoor Area: LPA toured the outside area of the facility and observed appropriate outdoor furniture, with a covered shaded area for residents. The backyard is fully fenced in with enough outdoor space for activities. Passageways to entrances and exits were clear of obstructions. Resident and Staff Files: Resident and staff files are maintained locked in a hallway walk-in closet. From 11:43 a.m. to 1:10 p.m., LPA conducted a file review of five (5) out of five (5) resident records to insure compliance of licensing forms. The first aid kit, residents medication and medication records are stored in a locked hallway walk-in closet. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR). LPA conducted a file review of three (3) staff records to ensure forms and training are up to date. One (1) out of the three (3) staff records reviewed did not have the annual 20 hours of training. LPA obtained a copy of the facilities updated liability insurance, and LIC500. LPA reviewed with the administrator the facility's emergency and disaster plan, infection control plan. LPA was not provided documentation of emergency type quarterly drills conducted for each shift in 2025. Deficiencies observed during todays visit, refer to LIC809-D. A copy of this report was provided. Appeal rights provided. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 15, 2025

Allegation investigated: There is no admission agreement.

On 05/06/2025 at 9:10 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct an unannounced complaint visit. Upon arrival, LPA met with staff and requested they contact the administrator. Staff contacted the Lead Caregiver. LPA met with the Lead Caregiver, Rocela Molina. According to Rocela the administrator is unavailable to meet in person but will be available by telephone. LPA Rios explained the reason for the visit. Rocela will be signing today's report. At approximately 9:16 a.m., LPA Rios began a physical plant tour of the facility to ensure the health and safety of the residents in care. From 9:20 a.m. to 10:10 a.m., while conducting the tour of the facility LPA Rios interviewed four (04) of five (05) residents. One (01) resident, Resdient #2 (R2) did not respond to LPA's questions. From 10:05 a.m. to 10:30 a.m., LPA Rios interviewed three (03) staff. From 10:30 a.m. to 12:00 p.m., LPA reviewed five (05) of five (05) resident records and obtained copies of Resident #1(R1's) admission agreement. (Continue to LIC9099-C) Substantiated (Continued from LIC9099-A) LPA also obtained copies of the facility's resident roster, personnel report, unusual incident reports regarding R1 and staff notes. Allegation: Staff speak inappropriately to residents in care. It was alleged that Staff #1 (S1) made an inappropriate comment to R2 and yelled at R1. LPA's interview with four (04) residents revealed three (03) out of the four (04) residents have not witnessed staff speaking inappropriately to residents and have not been spoken to inappropriately by staff. The three (03) residents also denied witnessing S1 yell at residents and denied being yelled at by S1. One (01) out of the four (04) residents confirmed they have been yelled at by S1 and have witnessed S1 make an inappropriate comment to R2. Interview with three (03) staff deny witnessing any staff speaking inappropriately or yelling at any residents. According to the Lead Caregiver S1 assisted R2 with meals in R2's bedroom. LPA Rios was unable to corroborate the allegation. Based on interviews there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not ensure residents receive personal privacy. It was alleged that staff would walk into bedrooms without knocking. LPA's interview with four (04) residents revealed three (03) out of the four (04) residents have no issues or concerns regarding privacy. Three (03) residents state staff knock before they open the door and they have no preference regarding the door. One (01) resident stating they prefer to keep their door open. Interview with three (03) staff corroborate that they knock before entering a room except for R2's and resident #3's (R3's) room as they both do not respond to knocking at their door. According to staff interviews they also denied witnessing other staff walk into bedrooms without knocking LPA's interview with R1 revealed they believed S1 would linger at their door or pass by every time they were on a phone call to eavesdrop on their conversation. According to the Lead Caregiver S1 assisted R2 in their bedroom which forces them to pass by R1's bedroom. LPA Rios was unable to corroborate the allegation. Based on interviews there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC9099-C) (Continued from LIC9099-C) Allegation: Staff threatened to evict resident. It was alleged that the owner of the facility verbally threatened to evict R1. Interview with the lead caregiver revealed that they did not issue any eviction notices to R1 or their responsible person. During the investigation R1 and staff provided LPA with a copy of a letter dated 03/19/2025 from the owner given to R1 explaining that R1 has expressed dissatisfaction with the facility and due to R1's behavior towards staff the owner would like R1 to explore alternative care options or to move to a place that would meet R1's standards. Review of Unusual Incident/Injury Reports from 02/05/2025 to 04/07/2025 submitted to Long Term Care Ombudsman revealed R1 has had ongoing incidents involving certain staff. LPA's interview with Administrator, Jerome Viray at 4:25 p.m., denied the allegation stating they are trying to communicate with R1 and involved R1's family to resolve issues but have not been successful. According to the administrator the letter provided to R1 was not an eviction notice. Based on interviews and record review there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff do not provide adequate food service. It was alleged that the facility will run out of food towards the end of the month. During LPA's tour of the facility LPA observed one (01) resident eating a breakfast meal that contained scrambled eggs, cut up sausages, and a blueberry waffle. LPA's interview with the Lead Caregiver revealed R1 will complain that the caregivers are only preparing Filipino food. According to the Lead Caregiver they cook different kinds of meals and the residents have other options if they do not want to eat what is being prepared. LPA toured the kitchen and observed adequate amount of food. During the investigation LPA obtained a copy of the weekly menu for a month. LPA's review of the menu revealed that the facility is serving a variety of food to residents. Interview with three (03) out of four (04) residents revealed they like the food being served and feel that they receive an adequate amount. Based on interviews and record review there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided. (Continued from LIC9099) Allegation: There is no admission agreement. In regards to the allegation it is being reported that their is no admission agreement between Resident #1(R1) and facility. To investigate the allegation LPA Rios reviewed R1's records. LPA's review of R1's admission agreement revealed admission agreement on file is between R1 and another facility, Club Rancho Manor Inc. with admission date 09/21/2024. LPA's interview with the Lead Caregiver, revealed R1 was initially admitted to the other facility and was only their for a few days because R1 was in and out of the hospital. R1 then requested to be moved out due to concerns about staff qualifications. R1 was then moved to this facility on 10/01/2024. Facility was unable to provide an admission agreement between R1 and this facility. Admission agreement on file with the facility contains a note on the upper right corner that states, "Transferred to Alexo on Oct 1, 2024 with a revised rate". LPA did not observe a new signature or date next to the written note. Based on record review and interviews, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited (refer to LIC 9099-D). Exit interview conducted. Appeal Right provided. Copy of report provided.the state’s words, verbatim · CDSS document, May 6, 2025 · control 31-AS-20250428084431

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: May 16, 2025

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Based on interviews, and record review Licensee failed to complete a written admission agreement with R1 for this facility with admission 10/01/2024 which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Licensee will email LPA a scanned copy of completed agreement between R1 and this facility by POC due date 05/16/2025.

Type of visit: Case Management - Deficiencies

In conjunction with control number 31-AS-20250428084431 complaint visit, Licensing Program Analyst (LPA) Evelin Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. A case management report is being issued today in conjunction to the complaint visit report for observed deficiencies not related to complaint. LPA met with Rocela Molina - Lead Caregiver. Interview with staff revealed there was a staff #1 (S1) who provided care to residents in the facility. Review of S1's record and Guardian Background Check revealed S1 is not fingerprinted cleared. Review of five (05) out of (05) resident records revealed resident #4 (R4) had after visit paperwork from emergency room visits. According to the Lead Caregiver, R4 had medical emergencies that required the facility to contact 911 on separate occasions. Review of Community Care Licensing Division (CCLD) records revealed the facility had not submitted Unusual Incident/Injury Report to CCLD. Review of R1's record revealed the facility submitted Unusual Incident/Injury Reports from 02/05/2025 to 04/07/2025 to Long Term Care Ombudsman about R1's ongoing interactions involving certain facility staff. Review of Community Care Licensing Division (CCLD) records revealed the facility had not submitted Unusual/Injury Incident Reports to CCLD. Deficiencies observed and cited (Refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of Report Issued.the state’s words, verbatim · CDSS document, May 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d)(3) · Plan of correction due date: May 7, 2025

(d) All individuals subject to a criminal record review shall be fingerprinted...(3) The licensee shall submit these fingerprints to the California Department of Justice... prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above, in one staff identified was not fingerprint cleared for the facility. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: According to the Lead Caregiver the staff is no longer working in the facility. Licensee with review the regulation cited and submit a statement of understanding to LPA by POC due date 05/07/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: May 16, 2025

(a) Each licensee shall furnish to the licensing agency... the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above, in incidents involving R4 and R1 not reported to CCLD within seven days of occurrence which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: Lead Caregiver provided Unusual Incidents/Injury Reports involving R1 to LPA on todays visit. Licensee will submit Unusual incident reports of R4 to LPA by POC due date 05/16/2025.

Type of visit: Required - 1 Year

On 12/03/2024 at 9:15 a.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at the facility mentioned above. LPA was greeted by staff #1 (S1) who granted access. LPA observed appropriate postings on the entry and hallway wall. Staff #2 (S2) contacted the administrator. Administrator Designee, Stephanie Domingo met with LPA at the facility. LPA informed Stephanie of the purpose of the visit. At approximately, 9:20 a.m. a physical tour was conducted and LPA observed the following: Dinning area: LPA observed a large table with seating. Area was clean and clear of clutter. Dinning table and chairs appeared to be in good repair and sit the capacity of the facility. Bedrooms: LPA observed, six (6) resident bedrooms with sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. LPA observed over the counter medication on resident #4's (R4's) bedside table in bedroom #4. Stephanie removed it immediately. Review of R4's Physician's Report revealed they are not able to store own medications. LPA and Stephanie discussed the facility sketch and the approved fire inspection from 2019. LPA obtained a copy of current facility sketch with approved stamp from City of Lancaster Building and Safety for garage conversion. Administrator will submit an LIC 200 indicating caregiver bedroom from facility sketch in 2019 has been changed to resident bedroom #5. Bedroom #5 is currently vacant. Bathrooms: LPA observed three (3) bathrooms one (1) is located in a residents private bedroom. All bathrooms were clean and in good repair. Properly supplied with toilet paper, soap and paper towels. LPA observed appropriate grab bars, non-skid mats, and trash cans with fitted lids, to protect from cross contamination. (Continued on LIC809-C) (Continued from LIC809) The hot water temperature was taken from two (2) shared bathroom at approximately 10:26 a.m. and measured between 111.9°F and 114.3 120°F, within regulation.. Kitchen: LPA toured the kitchen area and observed S2 preparing breakfast for residents. LPA observed a 7 day non-perishable and 2 day perishable supply of food; properly stored. All knives and sharps were observed locked in a kitchen cabinet and inaccessible to residents. LPA observed a fire extinguisher fully charged with service date 11/14/2024. LPA observed four (4) telephones in the facility accessible to residents. Outdoor Area: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. LPA observed a small shed used for storage. LPA also observed a vegetable garden. Living Room: LPA observed the living room to be clean and furniture appeared to be in good repair. A fire place was observed, secured with a screen. Smoke detectors were located throughout the facility, and were tested at 10:32 a.m., they were observed to be operational. LPA observed a carbon monoxide detector that appeared operational. Facility is also equipped with two fire doors and fire sprinklers. Laundry Room: LPA observed door to laundry room locked. Cleaning supplies such as chemicals and detergents are kept locked in the laundry room. Resident and Staff Files: Resident and staff files are maintained locked in a hallway walk-in closet. From 11:12 a.m. to 1:10 p.m., LPA conducted a file review of five (5) resident records to insure compliance of licensing forms and also conducted a file review of three (3) staff records to insure forms and training are up to date. Review of R4's admission agreement revealed, R4's representative and Licensee's representative signatures and dates were missing. Two (2) staff records did not have active 1st Aid and CPR certification on file. LPA reviewed liability insurance, infection control and LIC500. Medications: Medication and Medication Records are stored in a locked hallway walk-in closet. Medications were reviewed for proper storage and documentation at 2:12 p.m. Facility also uses a Medication Administration Record (MAR). Deficiency cited, refer to LIC809-D. Exit interview conducted. A copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: Required - 1 Year

On 11/13/2023 at 9:55 a.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at the facility mentioned above. LPA was greeted by staff #1 (S1) who granted access. LPA observed appropriate required postings on the entry and hallway wall. S1 contacted the administrator. LPA informed Administrator of the purpose of the visit. Administrator, Stephanie Domingo joined us shortly after the physical tour was concluded. At approximately, 10:00 a.m. a physical tour was conducted with S1 and LPA observed the following: Formal Dinning area: LPA observed a large table with seating. Area was clean and clear of clutter. Dinning table and chairs appeared to be in good repair and sit the capacity of the facility. Kitchen/Breakfast table: LPA toured the kitchen area and observed staff #2 (2) preparing food for residents. LPA observed a 7 day non-perishable and 2 day perishable supply of food; properly stored. All knives and sharps were observed locked in a kitchen cabinet and inaccessible to residents. Cleaning supplies were locked in a kitchen cabinet under the sink. LPA observed a fire extinguisher fully charged. Living Room: LPA observed the living room to be clean and furniture appeared to be in good repair. A fire place was observed and not in use, secured with a screen. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:26 a.m. they were tested and observed to be operational. LPA observed fire doors and fire sprinklers. Bedrooms: There are ten (10) bedrooms, six (6) of which are designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Four (4) out of the ten (10) bedrooms are for staff and are kept locked. (Continued on LIC809-C) (Continued from LIC809) Bathrooms: LPA observed three (3) bathrooms one (1) is located in a residents private bedroom. All Bathrooms were clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bars, non-skid mats, and trash cans with fitted lids to protect from cross contamination. The hot water temperature was taken at 10:30 a.m. and measured at 120°F. Auditory alarms were tested and observed to be operational. Laundry room: LPA observed door to laundry room locked. Chemicals and detergents are kept in laundry room locked. Outdoor Area: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. LPA observed a small shed storing furniture and other facility items. LPA also observed a hobby farm; facility is growing their own vegetables. Resident and Staff Files: Resident and staff files are maintained locked in a hallway walk-in closet. LPA conducted a file review of resident records to insure compliance of licensing forms from 10:45 a.m. to 12:33 p.m. Review of residents with special health needs records revealed three (3) residents with dementia (resident #1 (R1), resident #2(R2) and resident #4 (R4)) did not have an annual medical assessment done. LPA also conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing forms at 12:34 p.m. Medications: Medication and Medication Records are stored in a locked hallway walk-in closet. Medications were reviewed for proper storage and documentation at 1:09 p.m. Facility also uses a Medication Administration Record (MAR). LPA conducted resident and staff interviews at 3:11 p.m. Deficiency cited refer to LIC809-D. Exit interview conducted. A copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Nov 13, 2023