198603140-10-6-2025-28-AS-BPEA-DM7R26-20251006123750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603140
Report Date: 10/06/2025
Date Signed: 10/06/2025 12:38:54 PM

Document Has Been Signed on 10/06/2025 12:38 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LEJENZ HOME CARE		FACILITY NUMBER:	198603140
ADMINISTRATOR/ DIRECTOR:	LEON, JENNIFER MANABAT		FACILITY TYPE:	740
ADDRESS:	384 S ROCK RIVER RD		TELEPHONE:	(909) 895-7199
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY: 6		CENSUS: 6	DATE:	10/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:28 AM
MET WITH:	Jennifer Manabat Leon - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Pandapotan Pardosi and oJcelyn Habaradas, Care Staff and explained the purpose of the visit. At 10:30am, Administrator Jennifer Manabat Leon arrived and assisted LPA with the inspection. The facility is approved to serve elderly residents age range 60 and over, (6) non ambulatory of which (3) may be bedridden. Facility is approved for (6) hospice waiver. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has Infection prevention and control plan, process, procedures and training plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date. Operational Requirements: Fire Drill is conducted quarterly and the last drill was conducted on 07/09/2025. Facility has working signal systems in exit points. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 06/01/2026. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the residents with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, (1) staff bedroom, (2) bathrooms, living room with covered fireplace, kitchen, dining area, laundry area in the attached garage and front yard with shaded patio area. There are currently (6) residents, of which (2) are under hospice care. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPA observed cameras outside the property. Front yard was inspected and has a shaded area and sitting area. There is (1) fire extinguisher in the facility which was serviced on 02/25/2025. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. @ 10:35am, readings were 110.4 deg. F in bathroom #1 and 111.9 deg F in bathroom #2. ***REPORT CONTINUED ON LIC809-C***

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEJENZ HOME CARE	FACILITY NUMBER: 198603140
	VISIT DATE: 10/06/2025

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
26
27
28
29
30
31
32

Staffing: A total of (11) regular and on-call caregivers including the (2) Administrators provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator's certificate is valid through 08/08/2026.
Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Information regarding Dementia is part of training for direct care staff. The facility provides sufficient space to accommodate both indoor and outdoor activities.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Facility has (2) extra refrigerators/freezers with food supplies in the garage. Pesticides and cleaning supplies are kept away from the food preparation areas.
Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications were stored in a locked cabinet in the hallway and inaccessible to residents. First-aid supplies along with a manual are maintained in the facility.
Resident Records-Incident Reports: Resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a monthly basis. Last fire and earthquake drills were conducted on 07/09/2025.
Residents with SHN: Two (2) residents are under hospice care. Physician orders for use of bed rails were reviewed in (6) resident files.

No deficiencies cited, Technical Assistance issued. Exit interview and a copy of this report was provided to the Administrator, Jennifer Manabat Leon.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5