197609919-5-6-2025-31-AS-EMIR-DK2PF3-20250729111605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609919
Report Date: 05/06/2025
Date Signed: 05/06/2025 05:10:37 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2025 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20250428084431

FACILITY NAME:	ALEXO MANOR INC		FACILITY NUMBER:	197609919
ADMINISTRATOR:	VIRAY, JEROME		FACILITY TYPE:	740
ADDRESS:	41453 ALEXO DRIVE		TELEPHONE:	(818) 332-6150
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	05/06/2025
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Rocela Molina - Lead Caregiver		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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There is no admission agreement.

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2025 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20250428084431

FACILITY NAME:	ALEXO MANOR INC		FACILITY NUMBER:	197609919
ADMINISTRATOR:	VIRAY, JEROME		FACILITY TYPE:	740
ADDRESS:	41453 ALEXO DRIVE		TELEPHONE:	(818) 332-6150
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	05/06/2025
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Rocela Molina - Lead Caregiver		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff speak inappropriately to residents in care.
Staff do not ensure residents receive personal privacy.
Staff threatened to evict resident.
Staff do not provide adequate food service.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 31-AS-20250428084431

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXO MANOR INC	FACILITY NUMBER: 197609919
	VISIT DATE: 05/06/2025

NARRATIVE

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(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)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250428084431

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXO MANOR INC	FACILITY NUMBER: 197609919
	VISIT DATE: 05/06/2025

NARRATIVE

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(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.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20250428084431

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXO MANOR INC	FACILITY NUMBER: 197609919
	VISIT DATE: 05/06/2025

NARRATIVE

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(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.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20250428084431

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXO MANOR INC	FACILITY NUMBER: 197609919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/16/2025 Section Cited CCR 87507(a)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Licensee will email LPA a scanned copy of completed agreement between R1 and this facility by POC due date 05/16/2025.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC9099 (FAS) - (06/04)

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