Inspection Reports for
Alexander Gardens

CA, 93105

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Citations (last 5 years)

Citations (over 5 years) 1 citations/year

Citations are regulatory findings recorded during state inspections.

75% better than California average
California average: 4 citations/year

Citations per year

4 3 2 1 0
2021
2022
2023
2024
2025

Occupancy

Latest occupancy rate 64% occupied

Based on a November 2025 inspection.

Occupancy rate over time

40% 60% 80% 100% Feb 2021 Sep 2021 Nov 2023 Nov 2024 Nov 2025

Inspection Report

Annual Inspection
Census: 23 Capacity: 36 Citations: 2 Date: Nov 7, 2025

Visit Reason
An unannounced required Annual Inspection was conducted to assess compliance with licensing requirements at the Residential Care Facility for the Elderly.

Findings
The facility was found to be in good repair with proper postings, clean environment, and adequate food and medication storage. However, deficiencies were cited related to clerical errors in staff criminal background clearance and association to the facility, posing immediate health and safety risks.

Citations (2)
Clerical error resulted in no criminal background clearance being completed for Staff 3 prior to working in the facility, posing an immediate health and safety risk.
Two staff members (S1 and S2) were not properly associated to the facility, posing an immediate health and safety risk.
Report Facts
Capacity: 36 Census: 23 Hospice waiver capacity: 20 Hospice residents: 5 Fire extinguisher inspection date: Nov 3, 2025 Plan of Correction Due Date: Nov 10, 2025

Employees mentioned
NameTitleContext
Mitchell LeichterAdministratorNamed as facility administrator, unavailable during inspection
Jackie BarronAssisted Living CoordinatorMet with Licensing Program Analyst during inspection
Dalia GutierrezBusiness DirectorUnavailable during inspection
Kristin KontilisLicensing Program AnalystConducted the inspection
Kelly BurleyLicensing Program ManagerNamed as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 25 Capacity: 36 Citations: 0 Date: Nov 12, 2024

Visit Reason
The inspection was an unannounced required annual evaluation visit to assess compliance with Title 22 regulations for a Residential Care Facility for the Elderly (RCFE).

Findings
The facility was found to be in compliance with health and safety regulations, including proper food service, clean and appropriate furnishings, adequate emergency preparedness, and proper medication storage. No hazards or violations were observed during the inspection.

Report Facts
Maximum capacity: 36 Bedridden residents allowed: 10 Hospice care waiver: 20 Inspection start time: 12 Inspection end time: 15

Employees mentioned
NameTitleContext
Brian PhillipsLicensing Program AnalystConducted the inspection and authored the report
Dalia GutierrezAssociate Executive DirectorFacility representative who met with the Licensing Program Analyst during the inspection
Mitchell LeichterAdministrator/DirectorFacility Administrator named in the report
Kelly BurleyLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 22 Capacity: 36 Citations: 1 Date: Dec 20, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/09/2021 regarding staff response times to resident call buttons and other resident care concerns.

Complaint Details
The complaint investigation was substantiated for the allegation that staff did not answer resident call buttons in a timely manner. Other allegations regarding staffing sufficiency, rough handling, dignity, and safeguarding belongings were unsubstantiated.
Findings
The investigation substantiated that staff did not respond to resident call buttons in a timely manner, with documented response times exceeding 20 minutes on multiple occasions. Other allegations including insufficient staffing, rough handling of residents, lack of dignity in staff-resident relationships, and failure to safeguard belongings were found to be unsubstantiated.

Citations (1)
Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall... This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when the signal system went unanswered for an extended period of time, which posed a potential health and safety risk to residents in care.
Report Facts
Call response times: 20 Call response times: 10 Call response times: 4 Call response times: 1 Call response times: 2 Facility capacity: 36 Facility census: 22

Employees mentioned
NameTitleContext
Kristin KontilisLicensing Program AnalystConducted the complaint investigation and issued final findings
Kelly BurleyLicensing Program ManagerOversaw the complaint investigation report
Dahlia GutierrezBusiness Office ManagerMet with Licensing Program Analyst during the investigation
Mitchell LeichterAdministratorFacility administrator mentioned in relation to staff performance and investigation

Inspection Report

Annual Inspection
Census: 26 Capacity: 36 Citations: 0 Date: Nov 20, 2023

Visit Reason
The inspection was an unannounced annual facility site inspection visit conducted to ensure compliance with Title 22 Regulations for a Residential Care Facility for the Elderly (RCFE).

Findings
The facility was found to be in compliance with all applicable regulations, including health and safety standards, kitchen and food service safety, common area conditions, resident bedrooms, restrooms, medication storage and administration, infection control, and facility documentation. No deficiencies were cited during the inspection.

Report Facts
Capacity: 36 Census: 26 Hospice Waiver: 20 Non-ambulatory residents: 36 Bedridden residents: 10 Kitchen hot water temperature range: 105 Kitchen hot water temperature range: 120 Restroom hot water temperature range: 105 Restroom hot water temperature range: 120

Employees mentioned
NameTitleContext
Mitchell LeichterAdministratorMet with Licensing Program Analyst during the inspection
Brian PhillipsLicensing Program AnalystConducted the annual facility site inspection visit

Inspection Report

Annual Inspection
Census: 25 Capacity: 36 Citations: 0 Date: Oct 20, 2022

Visit Reason
The inspection was a required unannounced 1-year infection control annual visit to evaluate compliance with infection control policies and procedures.

Findings
The facility demonstrated full implementation and adherence to infection control protocols including screening, PPE use, isolation procedures, and staff training. The facility maintains adequate PPE supplies, follows current guidance, and has valid certifications and safety equipment inspections.

Report Facts
PPE supply duration: 30 Resident medication supply duration: 30 Number of residents: 25 Facility capacity: 36

Employees mentioned
NameTitleContext
Corinne SatterthwaiteLicensed Vocational Nurse (LVN)In charge of infection control and provides training and education to staff, residents, and visitors
Mitchell LeichterAdministratorFacility Administrator with a plan in place for outbreak notification and emergencies
Karen DacomeAssociate Executive DirectorMet with Licensing Program Analyst during inspection and assisted with facility tour
Diego CortezLicensing Program AnalystConducted the on-site 1-year infection control annual visit
Kelly BurleyLicensing Program ManagerNamed as Licensing Program Manager overseeing the inspection

Inspection Report

Census: 26 Capacity: 36 Citations: 0 Date: Sep 29, 2021

Visit Reason
Licensing Program Analyst Kristin Kontilis conducted a Case Management visit to investigate various incidents that occurred from 7/18/2021 through 9/29/2021.

Findings
Due to time restraints, further investigation will be needed and the Licensing Program Analyst will return at a later date. No deficiencies were issued during this visit.

Employees mentioned
NameTitleContext
Kristin KontilisLicensing Program AnalystConducted the Case Management visit and interviews.
Mitchell LeichterAdministratorMet with Licensing Program Analyst during the visit.

Inspection Report

Complaint Investigation
Census: 26 Capacity: 36 Citations: 0 Date: Sep 29, 2021

Visit Reason
The visit was a Case Management investigation to review various incidents that occurred from 07/18/2021 through 09/29/2021 at the facility.

Complaint Details
Investigation of various incidents reported between 07/18/2021 and 09/29/2021; further investigation planned; no deficiencies issued at this time.
Findings
The Licensing Program Analyst conducted interviews and requested documents related to the investigation but due to time constraints, further investigation was needed. No deficiencies were issued during this visit.

Employees mentioned
NameTitleContext
Mitchell LeichterAdministratorMet with Licensing Program Analyst during investigation
Kristin KontilisLicensing Program AnalystConducted the Case Management visit and investigation
Kelly BurleyLicensing Program ManagerNamed in report header

Inspection Report

Follow-Up
Census: 25 Capacity: 36 Citations: 1 Date: Jul 16, 2021

Visit Reason
This Case Management visit was conducted to address deficiencies noted during a complaint investigation visit on 7/16/2021, specifically to discuss the serious illness/injury reporting requirement as per regulation 87211(a)(1)(D).

Complaint Details
The visit was conducted to address deficiencies noted during Complaint Control #29-AS-20210709080012 investigation visit conducted on 7/16/2021.
Findings
The visit found that four fall incidents occurred between 6/25/2021 and 7/16/2021 that were not reported to the Community Care Licensing (CCL) as required, posing an immediate health and safety risk to residents.

Citations (1)
Failure to report serious illness/injury incidents (four fall incidents between 6/25/2021 and 7/16/2021) to CCL as required by regulation 87211(a)(1)(D).
Report Facts
Fall incidents not reported: 4 Capacity: 36 Census: 25

Employees mentioned
NameTitleContext
Dahlia GutierrezBusiness Office ManagerStated that the falls were not reported to CCL during the visit.
Kelly BurleyLicensing Program ManagerSupervisor named in the report.
Kristin KontilisLicensing Program AnalystLicensing evaluator who conducted the visit and signed the report.

Inspection Report

Complaint Investigation
Census: 25 Capacity: 36 Citations: 1 Date: Jul 16, 2021

Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 07/09/2021 regarding restricted visitation at the facility.

Complaint Details
The complaint alleging restricted visitation was substantiated based on interviews and document reviews showing visitation was limited to two visitors at specific times and days by appointment only.
Findings
The investigation substantiated that the facility restricted visitation by allowing residents only two visitors at a time on specific days and times by appointment only, which is a violation of residents' personal rights and poses an immediate health and safety risk.

Citations (1)
Failure to allow residents to have visitors, including ombudspersons and advocacy representatives, visit privately during reasonable hours and without prior notice, infringing on residents' personal rights.
Report Facts
Capacity: 36 Census: 25 Visitors allowed: 2 Visitation days: 4 Visitation times per day: 3 Visitation duration: 30

Employees mentioned
NameTitleContext
Kristin KontilisLicensing Program AnalystConducted the complaint investigation and authored the report
Kelly BurleyLicensing Program ManagerOversaw the complaint investigation process
Dalia GutierrezBusiness Office ManagerInterviewed during investigation and involved in visitation policy discussions

Inspection Report

Follow-Up
Census: 20 Capacity: 36 Citations: 0 Date: Feb 17, 2021

Visit Reason
The visit was a case management follow-up conducted telephonically due to a self-reported incident involving Resident #1 who alleged personal rights violations by Staff #1 on three separate occasions.

Complaint Details
The visit was triggered by a complaint from Resident #1 regarding personal rights violations by Staff #1, which is under investigation.
Findings
No immediate health and safety hazards were observed during the visit. Staff #1 is on leave pending investigation, and further investigation will be conducted by the Community Care Licensing Division's Investigations Branch.

Employees mentioned
NameTitleContext
Mitchell LeichterAdministratorMet with Licensing Program Analyst during the case management visit and involved in the telephonic exit interview.
JoAnn RosalesLicensing Program AnalystConducted the case management visit telephonically.
Douglas RealInvestigatorCommunity Care Licensing Division's Investigations Branch Investigator assigned to further investigation.

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