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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603447
Report Date: 05/11/2023
Date Signed: 05/12/2023 08:26:47 AM

Document Has Been Signed on 05/12/2023 08:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lara Langa TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with DSP Celia Bugayong who allowed the entry of the facility and Shortly after, the assistant administrator Lara Langa arrived and assisted with the visit. The purpose for the visit was explained. The facility is licensed for AGE RANGE 18 THROUGH 59. APPROVED FOR 6 AMBULATORY, OF WHICH 2 MAY BE NON-AMBULATORY. BEDROOM #2 APPROVED FOR NON-AMBULATORY.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and here are the domains that LPA inspected:

1, Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and has an Infection Control Plan.
2. Physical Plant and Environmental: The facility is a single story house and located around the residential neighborhood area. The facility includes: living room, dining area, kitchen, four clients bedrooms, two bathrooms, live in staff room and an attached garage with laundry area and for storage use. LPA inspected the carbon monoxide detector which is mounted on the wall near the dining area and working probably. The smoke detectors are located in each room and common area and they are working well. LPA tested the hot water temperature in two clients bathrooms and kitchen and they were tested between 105 and 110.2 degrees F. which are within the Title 22 regulation. All the sharp knives and utensils are locked in the kitchen drawer. All the cleaning supplies and chemicals are locked in the storage room in the garage. The facility has sufficient personal hygiene products for clients to use. All clients rooms are furnished and have required beddings. All the bathrooms are clean, sanitized and operational. The exit and passage way are safe and free of obstruction.

(See LIC 809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LEMON TREE HOME LIVING
FACILITY NUMBER: 198603447
VISIT DATE: 05/11/2023
NARRATIVE
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3. Operational Requirements: The facility maintained a fire clearance approved by the fire department which 2 may be non-ambulatory. Currently All the clients in the facility are ambulatory. The facility also has shaded area with table and chairs for client to utilize for outdoor activity. The last fire/disaster drill was conducted on 4/24/23.
4. Staffing: The facility has sufficient staffing and the night supervision staff did receive planned emergency training.
5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator (Anthony Ngo) certificate will be expired on 11/3/2025 . The administrator did not have an updated HIV and TB training certificate and the last one was completed on 04/2020. All the direct care staff received Medication Management Training. The first aid training for Staff#1 and #2 were expired on 03/2023.
6. Clients Right-Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.
7. Client Records-Incident Reports: All the client files are stored in the cabinet next to the dining area and maintained in the facility. All the files have the required documents included: admission agreement, updated physician report , Individual Personal Plan (IPP) and functional capacity assessment..etc.
8. Food Service: The facility has two days perishable and seven days non-perishable food supply. The refrigerator is maintained in the required temperature. All the food are stored probably.
9. Health Related Services: All client medication are centrally stored and locked in the cabinet near the dining area. All the client's medication are reviewed and they are all accurate and updated.
10. Incidental Medical Services: The facility does not have any client who has the restricted health condition or prohibited health condition.
11. Disaster Preparedness: The facility does not have an updated Emergency Disaster Plan LIC610D 12/21 and last one was completed on 05/2021.
12. Emergency Intervention: Its not applied for the facility as the facility is not a behavioral home.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the assistant administrator Lara Langa.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/12/2023 08:26 AM - It Cannot Be Edited


Created By: Christine Wong On 05/11/2023 at 03:37 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: LEMON TREE HOME LIVING
FACILITY NUMBER: 198603447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on the record review, LPA observed the adminsitrator training for HIV and TB was expired on 04/2020 which posed a potential risk to clients in care.
POC Due Date: 06/11/2023
Plan of Correction
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The administrator will ensure to receive training on HIV and TB every two years and will send the HIV and TB Training certificate to LPA by POC due date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, LPA observed the first aid certificate for Staff#1 and #2 was expired on 03/2023 which posed a potential risk to clients in care.
POC Due Date: 05/31/2023
Plan of Correction
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The adminsitrator will ensure staff who provide care and supervision shall receive training in first aid and the administrator will send the frist aid certificate for Staff#1 and #2 to LPA 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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/12/2023 08:26 AM - It Cannot Be Edited


Created By: Christine Wong On 05/11/2023 at 03:37 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: LEMON TREE HOME LIVING
FACILITY NUMBER: 198603447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed the facility emergency and disaster plan was dated on 05/2021 and its not updated annually which posed a potential risck to clients in care.
POC Due Date: 05/25/2023
Plan of Correction
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The administrator will ensure there's an updated emergency and disaster plan in the facility and its updated annually and the administrator will send the updated one LIC610D (12/21) to LPA by 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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4