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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603140
Report Date: 09/03/2021
Date Signed: 09/08/2021 02:21:29 PM

Document Has Been Signed on 09/08/2021 02:21 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LEJENZ HOME CAREFACILITY NUMBER:
198603140
ADMINISTRATOR:LEON, JENNIFER MANABATFACILITY TYPE:
740
ADDRESS:384 S ROCK RIVER RDTELEPHONE:
(909) 895-7199
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 4DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jennifer Leon, administratorTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicole Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer was greeted by caregivers in charge and was later assisted by administrator Jennifer Leon and discussed the purpose of today's visit. This single-story home contains five (5) bedrooms, two (2) bathrooms, a living room, kitchen, dining room, backyard, and attached garage. One (1) bedroom is designated as a caregiver's room.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, hand sanitizer, masks, and sign-in sheet. A temperature check log for staff and residents was maintained daily.
  • COVID-19 signage was placed in several areas including entrance, hallways, and bathrooms.
  • Facility maintained a 30-day supply of PPE.
  • Staff wore face masks throughout their shift and furniture was placed to encourage physical distancing.
  • There was a sufficient supply of 7-day non-perishable foods, but an insufficient supply of 2-day perishable foods including fresh fruits and vegetables.
  • Cleaning solutions and sharps were locked and inaccessible.
  • Water temperature was measured and were within required 105-120 degrees F.
  • All resident rooms contained required furniture including bed, dresser, night stand, lamp and chair.
  • Medications were locked and centrally stored, however, medication administration errors were observed.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Indoor passageways were not free from obstruction as a caregiver bed was placed in a common area.
  • A fire extinguisher was observed to be fully charged and last serviced on April 2021.
  • One (1) area of disrepair was observed. An approximately 30 inch hairline crack was located on a resident's bedroom window.
***See 809C for continuation of this narrative***
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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 09/08/2021 02:21 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 09/03/2021 at 03:10 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEJENZ HOME CARE
FACILITY NUMBER: 198603140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due a lack of fresh fruits and vegetables which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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The administrator bought a new supply of fresh fruits and vegetables to restock the fridge and stated that they had a planned grocery trip scheduled for today. The deficiency was cleared prior to the end of the visit.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for two (2) medications: Losartan Potassium 50 mg and Quetia Fuma Sorequel 150 mg which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2021
Plan of Correction
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Administrator ordered the needed medication which will be delivered by tomorrow and will send CCL photo of medication by 9/4/21. Administrator will provide staff training on proper administration and documentation of medications and send training logs to CCL by 9/7/21 .
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2021 02:21 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 09/03/2021 at 03:10 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEJENZ HOME CARE
FACILITY NUMBER: 198603140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to a ~ 30 inch hairline crack in a resident's window which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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The administrator will have the cracked window repaired or replaced and will send a picture to CCL by 10/1/21.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in due to a caregivers bed placed in a common area hallway near the office. The administrator stated that this bed is used by night time caregivers which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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The administrator immediately removed the caregiver bed and placed it inside the designated caregivers room. The administrator was informed that beds can only be placed in bedrooms. The deficiency was cleared prior to the end of the visit.
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021


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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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LEJENZ HOME CARE
FACILITY NUMBER: 198603140
VISIT DATE: 09/03/2021
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  • Client files were inspected and emergency contact information was up to date for three (3) out of four (4) residents.
  • Staff files were inspected and contained required health screenings, criminal record clearances, and trainings. Administrator certificate expires 8/2022.


Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted and a copy of this report and appeal rights were provided to the administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC809 (FAS) - (06/04)
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