198602906-6-2-2026-11-AS-SLEO-DUNVXV-20260602165009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602906
Report Date: 06/02/2026
Date Signed: 06/02/2026 04:50:23 PM

Document Has Been Signed on 06/02/2026 04:50 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CN HOME #9		FACILITY NUMBER:	198602906
ADMINISTRATOR/ DIRECTOR:	LASHAWN M JENKINS		FACILITY TYPE:	735
ADDRESS:	2911 PACIFIC AVENUE		TELEPHONE:	(310) 612-0978
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY: 4		CENSUS: 4	DATE:	06/02/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator - La Shawn Jenkins		TIME VISIT/ INSPECTION COMPLETED:	04:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/02/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, La Shawn Jenkins. The purpose of the visit was explained, and the LPA was allowed entry to the facility. This facility is licensed to serve 4 non-ambulatory adults ages 18 to 59 years old. A total of 4 clients are currently residing in this facility. The Annual Licensing Fees are current. Facility Layout: The facility is a one-story house located on a main street. The home consists of: 4 client bedrooms; 1 closet with a washer and dryer; 3 full bathrooms; 1 great room with an entry room/living room area, 1 kitchen area, 1 dining area, 1 office area, and 1 living room; 1 detached garage; and an outside backyard patio area with shaded seating. (The detached garage is attached to another garage and on top of both garages there is a two-bedroom apartment. The apartment and one of the garages is not part of the facility. The apartment is currently vacant.) Outside Grounds: were toured and there are security or weapons on the premises. The outside grounds are not clear of hazards. The licensee indicated that they will clear the backyard and fix the leaking air conditioning pipe outside within a week.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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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Document Has Been Signed on 06/02/2026 04:50 PM - It Cannot Be Edited

Created By: Socorro Leandro On 06/02/2026 at 04:12 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CN HOME #9	FACILITY NUMBER: 198602906
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having a backyard that was cleared of hazards, having water damage and mold on the wall in the dining area, having a door that cannot open, and having a leaky AC pipe next to a door, having water damage in one of the bathrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	The licensee has agreed to fix said problems. The licensee will email pictures of proof of correction to Socorro.Leandro@dss.ca.gov

Type B

Section Cited

CCR

80066(e)

(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited in not having Staff 1's (S1) training record and there are no staff trainings regarding gastrostomy feeding, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	The Administrator has agreed to email said records to Socorro.Leandro@dss.ca.gov.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:

	Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC809 (FAS) - (06/04)

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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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CN HOME #9	FACILITY NUMBER: 198602906
	VISIT DATE: 06/02/2026

NARRATIVE

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Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Food supply was of good quality. Knives and toxins were kept inaccessible to clients in care. There is fire extinguisher in the kitchen area, and it was last serviced on 05/11/2026. There is a landline telephone on the kitchen counter top.

Great Room: There are 3 landline telephones, there are two in both living rooms and there is one on the office table. There is a videoconferencing device for clients. There are television sets, games, puzzles, board games, and art supplies. The dining room area has water damage on the walls.

Client Bedrooms: 4 out of 4 client bedrooms were toured. Beds had mandatory bedding supplies. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Each client had their own toiletry supplies.

Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries were accessible to clients. 1 bathroom has water damage on the wall. The hot water temperature measures 105.8 Fahrenheit.

Medications: were inaccessible to clients in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 4 out of 4 Medication Administration Records (MARs) were reviewed and they were current and up to date.

Garage: is split into two rooms. One room is used as a storage room for cleaning items and extra facility supplies. The second room is used as a storage room for facility records.

Miscellaneous: Documents are posted as mandated. The last fire, earthquake, and disaster drill was conducted on 05/11/2026. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. The surety bond number is 63368997 and it expires on 10/01/2026. The facility has bed linen supplies, cleaning supplies, and incontinent care supplies.

4 staff records were reviewed. 1 out of 4 staff records did not have documented training. There is no record regarding staff training for gastrotomy feeding.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC809 (FAS) - (06/04)

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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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CN HOME #9	FACILITY NUMBER: 198602906
	VISIT DATE: 06/02/2026

NARRATIVE

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4 client records were reviewed, 4 out of 4 client records had documentation. 1 client record had a Restricted Health Condition Care Plan but did not include the staff names that were trained and responsible for providing care.

A technical violation is being provided regarding Retention and Limitations.

Deficiencies are being cited based on observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted; Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC809 (FAS) - (06/04)

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