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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610710
Report Date: 04/30/2025
Date Signed: 04/30/2025 11:29:17 AM

Document Has Been Signed on 04/30/2025 11:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALEXANDRIA RESIDENTIAL CARE LLCFACILITY NUMBER:
197610710
ADMINISTRATOR/
DIRECTOR:		GRABICKI, PETERFACILITY TYPE:
740
ADDRESS:16652 JERSEY STTELEPHONE:
(509) 368-4802
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
04/30/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Peter Grabicki, Maritess GrabickiTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicants, Peter and Marites Grabicki. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on September 24, 2024. A fire clearance was approved on October 23, 2024 for four (4) non-ambulatory residents, one (1) bedridden resident, and one (1) ambulatory for a total capacity of six. The facility is a one story building. The smoke alarms and carbon monoxide detector are dual and inter-connected. The fire extinguisher is located at the living room. The charge date is October 21, 2024.

A tour of the physical plant was initiated at approximately 10:00am and the following was observed:

KITCHEN: The kitchen is equipped with a refrigerator, microwave oven and sink. There is an adequate supply of nonperishable food items on stock. Perishable food items not required at this time as facility has zero (0) census. Applicants were advised to purchase perishable food items once licensed and facility starts operating. Applicant has enough dining ware to accommodate a maximum capacity of six (6). Knives/sharps and cleaning supples were observed locked in a kitchen cabinet. First aid kit and manual is maintained in a kitchen cabinet.

BEDROOMS: There are four (4) bedrooms designated for client use. Per STD 850, Bedroom #1 has the bedridden fire clearance. Bedrooms #2 and #3 are shared. Bedroom #4 is ambulatory only. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2025
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALEXANDRIA RESIDENTIAL CARE LLC
FACILITY NUMBER: 197610710
VISIT DATE: 04/30/2025
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BATHROOMS: The facility has three (3) bathrooms. Bedrooms #1 and #4 has it's own bathroom with shower. The third bathroom is located in the hallway by bedrooms #2 and #3. All three bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 120 degrees.

COMMON AREAS: These included the living room and dining room. The living room is furnished with two couches, one recliner and one television. There is a fireplace that is screened with a glass door. Fireplace is non-functional. The dining room table is large enough to seat up to six (6). Floors and furniture were observed to be maintained and in good repair. Entry and exits were clear of obstruction.



LAUNDRY: The washer/dryer is located in the kitchen.

MEDICATIONS: The medications will be kept locked in individual drawers in the staff office.

OFFICE/STAFF WORKSTATION: Staff office is located by the living room, where resident and staff records will be kept in a locked drawer.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space to hold outdoor activities. There is no swimming pool or any other bodies of water. There is an ADU at the side of the home. Per STD 850, not part of the fire-clearance. ADU will only be used as staff break room.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment is compliant and ready for licensure. CAB will be advised and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC809 (FAS) - (06/04)
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