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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801995
Report Date: 07/16/2021
Date Signed: 07/16/2021 06:38:02 PM

Document Has Been Signed on 07/16/2021 06:38 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALEXANDER GARDENSFACILITY NUMBER:
425801995
ADMINISTRATOR:LEICHTER, MITCHELLFACILITY TYPE:
740
ADDRESS:2120 SANTA BARBARA STTELEPHONE:
(805) 682-9644
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY: 36CENSUS: 25DATE:
07/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Dahlia Gutierrez, Business Office ManagerTIME COMPLETED:
05:45 PM
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This Case Management visit was conducted to address deficiencies noted during Complaint Control #29-AS-20210709080012 investigation visit conducted on 7/16/2021. The Case Management visit is being conducted to discuss the serious illness/injury reporting requirement as per regulation 87211(a)(1)(D) Reporting Requirements.
During today’s visit, documents reviewed revealed fall incidents occurred between 6/25/2021 and 7/16/2021. Dahlia Gutierrez, Business Office Manager stated the falls were not reported to CCL. LPA advised Gutierrez that serious illness/injuries are required to be reported to CCL within seven (7) days of the incident(s) as required by California Code of Regulations.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Copy of report issued. Appeal Rights issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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 07/16/2021 06:38 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 07/16/2021 at 04:25 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALEXANDER GARDENS
FACILITY NUMBER: 425801995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements: ...Any incident which threatens the welfare, safety or health of any resident...

This requirement is not met as evidenced by:
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Business Office Manager agrees to conduct a staff training to cover 87211 in its entirety. Manager will submit a written document stating date of training, duration of time of training, attendees (F/L name w/signature and pritned names), and full description of training.
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Based on records reviewed and interviews conducted four (4) fall incidents occurred between 6/25/2021 and 7/16/2021 that were not reported to CCL as required. This poses an immediate health and safety risk to residents in care.
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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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021


LIC809 (FAS) - (06/04)
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