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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603447
Report Date: 05/10/2022
Date Signed: 05/10/2022 08:44:30 PM

Document Has Been Signed on 05/10/2022 08:44 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:LEMON TREE HOME LIVINGFACILITY NUMBER:
198603447
ADMINISTRATOR:NGO, ANTHONY PA-CFACILITY TYPE:
735
ADDRESS:19328 BAELEN STREETTELEPHONE:
(626) 269-0822
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 5DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Lara LangaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with DSP Jeffrey Anit and explained the reason for the visit. Shortly after, the co-administrator Lara Langa arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood. The facility consists of living room, kitchen, dining area, four clients bedrooms, two bathrooms, one live in staff bedroom, laundry room and a attached garage. All 4 clients bedrooms were toured. Bedroom#1 has one bed, one chair, one night stand, required linen and furniture and sufficient lighting and closet space. Bedroom#2 has two beds, two closet, required linen and furniture and sufficient lighting. Bedroom#3 has one bed, one chair, one night stand, required linen and furniture and sufficient closet space and lighting. Bedroom#4 has two beds, two drawers, required linen and furniture and sufficient lighting and closet space. All 2 clients bathrooms were toured and they are clean, sanitary and operational. The hot water temperature in two bathrooms were measured between 118 and 118.9 degrees F which is within Title 22 regulation. The refrigerator and kitchen cabinet has sufficient two days perishable and seven days non perishable food. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and back yard has a shaded area and sitting area and is available for client to use. The exit and passage way are free of obstruction. The smoke detectors are working properly and they are located in each bedroom and common area. The sharp knives and utensils are stored and locked in the kitchen cabinet. All toxic and cleaning supplies are stored in the garage which is inaccessible to clients.

During the inspection. LPA reviewed 5 clients medications and they are all accurate, current and updated in MARs. LPA also reviewed two staff files and confirmed and they do have health screenings on file and they both are fingerprint clearances.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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: LEMON TREE HOME LIVING
FACILITY NUMBER: 198603447
VISIT DATE: 05/10/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each client's room and facility is disinfected every day. All bathrooms have sufficient soap, paper towels, and signs, and PPE supplies are sufficient for more than 30 days

No deficiencies were found during this visit. Exit interview was conducted with Co-Administrator Lara Langa and a copy of this report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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