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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609919
Report Date: 12/15/2025
Date Signed: 12/15/2025 03:10:41 PM

Document Has Been Signed on 12/15/2025 03:10 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALEXO MANOR INCFACILITY NUMBER:
197609919
ADMINISTRATOR/
DIRECTOR:		VIRAY, JEROMEFACILITY TYPE:
740
ADDRESS:41453 ALEXO DRIVETELEPHONE:
(818) 332-6150
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 5DATE:
12/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Richard Garcia - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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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)
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALEXO MANOR INC
FACILITY NUMBER: 197609919
VISIT DATE: 12/15/2025
NARRATIVE
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(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.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2025 03:10 PM - It Cannot Be Edited


Created By: Evelin Rios On 12/15/2025 at 02:37 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXO MANOR INC
FACILITY NUMBER: 197609919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of three staff not having documented the annual 20 hours of training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
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Administrator agrees to conducted the required annual training for each staff that has not completed their annual training and provide a copy of the training and sign in sheet to LPA by POC due date 1/02/2026.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having conducted or documented a quarterly emergency disaster drill for the year 2025 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
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Administrator agrees to conducted an emergency disaster drill training for each shift and provide a copy of the sign in sheet to LPA by POC due date 1/02/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
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