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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603290
Report Date: 06/08/2023
Date Signed: 06/08/2023 02:11:23 PM


Document Has Been Signed on 06/08/2023 02:11 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 CARE IIFACILITY NUMBER:
198603290
ADMINISTRATOR:LEON, JENNIFER MANABATFACILITY TYPE:
740
ADDRESS:503 DOLE COURTTELEPHONE:
(909) 895-7680
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 6DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Administrator / Jennifer LeonTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 year continuation inspection using the full Care Compliance and Regulatory Enforcement (CARE) Tools. Upon arriving at the facility, LPA met with Administrator / Jennifer Leon who assisted with the visit. LPA explained the purpose of this visit. The facility is licensed to serve for a capacity of six (6) Residents ages 60 and over. The facility has an approved fire clearance for five non-ambulatory residents and one bedridden resident, designated to room #4. Hospice care waiver approved for six (6) residents. Currently, there are six (6) residents in placement. There is one (1) bedridden resident and four (4) residents receiving hospice services. The facility has an approved Dementia Care plan as part of its plan of operation and accepts/cares for residents with dementia.

During the initial Required - 1 Year inspection conducted on 6/2/23, LPA Katrdzhyan observed and reviewed the following (CARE) tool domains: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Food Service and Health Related Services/Incidental Medical & Dental.

As part of today's inspection, LPA observed and reviewed the remaining (CARE) tool domains: Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Planned Activities, Disaster Preparedness and Residents with Special Health Needs.

Personnel Records/Staff Training:

  • Administrator's Certificate is current and expires on 8/8/2024.
  • Staff have criminal background clearance and training.
  • A random selection of staff files were reviewed. First Aid/CPR training, Personnel Record, Health Screening, Criminal Record Statement, Employee Rights and Staff Training.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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 3


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 II
FACILITY NUMBER: 198603290
VISIT DATE: 06/08/2023
NARRATIVE
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Resident Records/Incident Reports:
  • A random selection of resident files were reviewed. Admission Agreement, Physician's Report, Consent Forms, ID & Emergency Information, Appraisal & Needs Service Plan, Immunization/TB clearance, Centrally Stored Medication Destruction Record, Safeguards for Property Valuables and Personal Rights.
  • The Incident report binder was reviewed.

Resident Rights/Information:

  • RCFE complaint poster and Personal rights were observed posted.
  • Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints was posted.

Planned Activities:

  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar is posted in a centralized location.


Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
  • Records of resident Appraisal and Needs services plans are part of Emergency training.


Residents with Special Health Needs:
  • One (1) resident is receiving home health services. There is one (1) bedridden resident and four (4) residents receiving hospice services.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 II
FACILITY NUMBER: 198603290
VISIT DATE: 06/08/2023
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  • Individual Service Plans and Appraisals are on file.
  • No residents have prohibited health conditions.


No deficiencies were observed during this visit.

An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3