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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603290
Report Date: 02/10/2026
Date Signed: 02/10/2026 04:15:02 PM

Document Has Been Signed on 02/10/2026 04:15 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LEJENZ HOME CARE IIFACILITY NUMBER:
198603290
ADMINISTRATOR/
DIRECTOR:		LEON, JENNIFER MANABATFACILITY TYPE:
740
ADDRESS:503 DOLE COURTTELEPHONE:
(909) 895-7680
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
02/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Jennifer Leon - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Jennifer Leon, Administrator and explained the purpose of the visit. The facility is approved to serve residents age range 60 and over, (6) non ambulatory, of (1) may be bedridden designated to room #4. Hospice waiver approved for (6) residents. 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 maintained. Staff are trained in the proper use of all required PPEs. Bathroom has hygiene items such as paper towel, hand soap and toilet paper.


Operational Requirements: Plan of operation and training logs were reviewed. The facility accepts and retains residents with dementia. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2026.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (7) bedrooms, (5) of which are resident bedrooms, (1) staff bedroom, (1) administrator/licensee room, (2) bathrooms, living room with covered fireplace, dining room, kitchen, attached garage, laundry area and backyard with patio area. There are currently (6) residents, (2) are under hospice care and (1) bedridden. The interior and exterior physical plant was inspected. Resident bedrooms were toured and each bedroom has the required furniture. Backyard was inspected and has a shaded area for outdoor activities. LPA observed a gardener working in the backyard installing water sprinklers during the visit. There are (2) fire extinguishers in the facility last serviced on 02/04/2025, however licensee, purchased a new fire extinguisher during the visit. Smoke detectors and carbon monoxide were tested and operable. There are no pools/ large bodies of water, firearms or weapons stored in the facility. The hot water temperature was measured between the required range of 105-120 degrees F.*****REPORT CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2026
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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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)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LEJENZ HOME CARE II
FACILITY NUMBER: 198603290
VISIT DATE: 02/10/2026
NARRATIVE
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Staffing: A total of (13) caregivers including the Administrator 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: Four (4) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator has completed the required administrator courses and 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. Administrator provides initial and ongoing training for staff.
Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. 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. Pesticides and cleaning supplies are kept away from the food preparation areas. (2) residents require modified/pureed diet.
Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are stored in a locked cabinet and inaccessible to residents.
Resident Records-Incident Reports: (6) 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. Emergency drill is conducted quarterly. Fire and earthquake drill was last conducted on 01/19/2026.
Residents with SHN: (2) residents are under hospice care and (1) resident is bedridden. Physician order for full bed rail was reviewed on the (5) residents' files except for (1) bedridden resident. There are no residents utilizing oxygen at this time.

Deficiencies cited. Technical violation and Technical Assistance issued.

Exit interview and a copy of this report along with the appeal rights were provided to the Administrator, Jennifer Leon.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/10/2026 04:15 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/10/2026 at 03:31 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 II
FACILITY NUMBER: 198603290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
87463 Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.
(1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that (2) residents diagnosed with dementia did not have a current medical assessment on file which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 02/18/2026
Plan of Correction
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Administrator will ensure that an annual routine visit is done and completed for residents with dementa. Administrator will obtain a current medical assessment for (2) residents and submit a copy to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87608(a)(3)

87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one of the residents who is bedridden did not have physician's order for a half bedrail on file which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 02/18/2026
Plan of Correction
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Administrator shall ensure that a written order from a physician indicating the need for bed rail in maintained in the resident's record. Administrator will send a copy of the physician's order for a 1/2 bedrail for one of the residents to LPA/CCL by 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2026


LIC809 (FAS) - (06/04)
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