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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 02:13:51 PM


Document Has Been Signed on 06/08/2023 02:13 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:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator / Jennifer LeonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Plan Of Correction (POC) visit to follow up on the deficiencies issued during the Required - 1 Year inspection conducted on 6/2/23. Upon arriving at the facility, LPA met with Administrator / Jennifer Leon who assisted with the visit. The purpose of this visit was explained.

On 6/2/23, the facility was cited for:

  • 87465(a)(4) Incidental Medical and Dental Care.
The licensee shall assist residents with self-administered medications as needed. On 6/2/23, LPA observed a discrepancy on the labels listed on two bottles of the same medications and the instructions listed on the Medication Administration Record (MAR) for Carbidopa-Levodopa 25/100mg. Bottle 1 of Carbidopa-Levodopa 25-100 Tab states, take 2 tablets by mouth 5 times daily. Bottle 2 of Carbidopa-Levodopa 25/100mg states, take 2 1/2 tablets by mouth 5 times daily. According to the Medication Administration Record states, staff are administering the medication by administering "3 tabs PO QID" (four times daily).

POC: On 6/2/23, LPA received a Physician's order for Carbidopa-Levodopa 25/100mg matching the instructions listed on the MAR "Take 3 tabs 4 times per day". Deficiency is cleared and no further action is needed.

  • 87465(a)(4) Incidental Medical and Dental Care.
The licensee shall assist residents with self-administered medications as needed. On 6/2/23, LPA observed an empty bottle of FOCUS CBD 25MG CBD gummies (chew 1 gummy PO QD (take once a day) and a new bottle with a refill was not available at the facility.

POC: On 6/2/23, LPA received a Physician's order discontinuing the FOCUS CBD 25MG CBD gummies/ Deficiency is cleared and no further action is needed.
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)
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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 II
FACILITY NUMBER: 198603290
VISIT DATE: 06/08/2023
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  • 87705(h) Care of Persons with Dementia
Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. On 6/2/23, LPA observed the exit gate located on the left side of the property facing the street is not enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. The self closing mechanism/latch on the exit gate located on the right side of the property facing the street, is inoperable and does not self close.

During today's visit, LPA observed self closing latches were installed on both exit gates and the exit gates were tested and operational at the time of visit. Deficiency is cleared and no further action is needed.


An exit interview was conducted and a copy of this report was provided.
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)
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