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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603290
Report Date: 06/02/2023
Date Signed: 06/08/2023 01:49:07 PM


Document Has Been Signed on 06/08/2023 01:49 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:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator / Jennifer LeonTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Required- 1 year visit 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.

The following (CARE) tool domains were observed and reviewed during today's visit: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Food Service and Health Related Services.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility is encouraging hand washing and self symptom check of staff and visitors. Each client bedroom is designated as a COVID-19 isolation room if needed and will use the closest restroom.

Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential area which consist of 2 living rooms, a kitchen, dining room, 5 resident bedrooms, 2 staff bedrooms, 2 bathrooms, a sun room/office, an attached garage/laundry area/storage and a backyard. No large bodies of water were observed.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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: 06/02/2023
NARRATIVE
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  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings were measured between the required 105 - 120 degrees Fahrenheit.
  • The attached garage is kept locked and inaccessible to residents at all times.
  • The facility has a Fire pull alarm located in the living room (near the main entrance).
  • 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.
  • The auditory chimes located on the exit doors in rooms 2 and 6 were observed to be inoperable.

Operational Requirements:
  • The Program Design was reviewed.
  • Fire clearance was approved by LA County Fire Department for five non-ambulatory residents and one bedridden resident, designated to room #4.
  • Care and supervision to meet the clients needs was observed.
  • No Surety bond is in place. Facility does not handle resident monies.
  • During today's visit, LPA was unable to verify the coverages listed on the Liability of Insurance as the facility renewed the policy effective 6/1/23 and a copy of a current Certificate of Liability Insurance has not been provided by the insurance carrier to the facility. LPA spoke with Licensing Program Manager Tony Vasallo, and was advised to obtain the renewal paperwork so that LPA Cynthia Chan can follow up with the Administrator. The Administrator was asked to provide a current copy of the Certificate of Liability Insurance to CCL within one week (6/9/23). No deficiency is issued today, per LPM Tony Vasallo.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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: 06/02/2023
NARRATIVE
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Staffing:
  • A total of ten staff members provide care and supervision to the clients.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • A random selection of resident medication records were reviewed. Centrally stored medications are kept in the closet located in the living room area (near the entrance door) and kept locked and inaccessible to residents in care.
  • During today's visit, 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 for Resident 1 (R1). 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).
  • During today's visit, LPA observed an empty bottle of FOCUS CBD 25MG CBD gummies (chew 1 gummy PO QD (take once a day) for R1 and a new bottle with a refill was not available at the facility.

Per California Code of Regulations, Title 22, deficiencies were cited.
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: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/08/2023 01:49 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
87705(j) Care of Persons with Dementia
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
The auditory chimes located on the exit doors in rooms 2 and 6 were observed to be inoperable.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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During today's visit, the Administrator installed new auditory chimes in bedrooms 2 and 6. The chimes were tested and operational. No further action is needed.
Type A
Section Cited
CCR
87465(a)(4)
87465(a)(4) Incidental Medical and Dental Care
The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
During today's visit, 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).
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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Administrator will obtain the correct labels on medications to match the physician order and submit proof of correction to CCL by the POC due date.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 06/08/2023 01:49 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465(a)(4) Incidental Medical and Dental Care
The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
During today's visit, 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.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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Administrator will obtain a refill of FOCUS CBD 25MG CBD gummies or a discontinue order and provide proof of correction to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 06/08/2023 01:49 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87705(h)
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.

This requirement is not met as evidenced by:
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.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Licensee will install a self closing latche on the exit gate located on the left side of the property facing the street and submit proof of correction to CCL by the POC due date.
Licensee will repair /replace the self closing mechanism/latch on the exit gates located on the right side of the property to ensure the safety of residents and submit proof of correction to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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