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Inspection visit

Follow-up on corrections

ALONDRA CARE HOME 3License 0192014663 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

While at the facility conducting inspection with Thinn Aye, administrator (ADM), for investigation of a complaint (Control # 15-AS-20250825103605), Licensing Program Analyst (LPA) Delmundo observed dividing walls and 2 beds in the garage. After granting of fire clearance by fire department on 1/22/25, and before granting of license, pre-licensing inspection was conducted by LPA on 3/13/25. LPA observed rooms with permanent walls installed in the garage. LPA reached out to fire marshal, and ADM had the rooms demolished. LPA reached out to fire marshal again regarding the dividing walls installed in the garage. Per fire marshal, the dividing walls are not allowed and that the demolition of the walls on the garage and the explanation of not using it as habitable space was conveyed prior.The garage can only be used if permitted and constructed per code, otherwise, it should remain a garage. On this day, 10/01/25, LPA learned and observed resident (R1) has 5 and 1 scratches/wounds on the lower right arm and left arm respectively caused by the dog in the facility. ADM stated the incident happened 2 days ago. On this same day, 10/01/25, the same dog came inside the facility and kept jumping on LPA. LPA also observed resident (R2) with two half bed rails on one side of the R2's bed, and R2 is not on hospice. .......continued on 809C Deficiencies, plan and proof of correction and civil penalty were discussed with ADM. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.269(a)(5)Type A

    §1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.-This is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section above when R1 sustained wounds/scratches caused by the dog in the facility.

  • 87203Type A

    87203 Fire SafetyAll facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.-This is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in have dividing walls in the garage and beds which pose an immediate risks to the safety risk to persons in care.

  • 87608(a)(5)(B)Type B

    87608 Postural Supports: (a) Postural supports may be used under the following conditions.(5)..(B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. -Based observation, the licensee did not comply with the section above in having full bedrails in R2's bed which poses a potential personal rights risk to person in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 1, 2025 inspection of ALONDRA CARE HOME 3?

This was a other inspection of ALONDRA CARE HOME 3 on October 1, 2025. 3 citations were issued: 2 Type A (serious) and 1 Type B.

Were any citations issued to ALONDRA CARE HOME 3 on October 1, 2025?

Yes, 3 citations were issued (2 Type A, 1 Type B). The first citation was for: "§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.