198603447-5-16-2024-28-AS-CWOG-D5BUNF-20240516154351

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603447
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:43:57 PM

Document Has Been Signed on 05/16/2024 03:43 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LEMON TREE HOME LIVING		FACILITY NUMBER:	198603447
ADMINISTRATOR/ DIRECTOR:	NGO, ANTHONY PA-C		FACILITY TYPE:	735
ADDRESS:	19328 BAELEN STREET		TELEPHONE:	(626) 269-0822
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 6		CENSUS: 4	DATE:	05/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:23 PM
MET WITH:	Lara Langa		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Anthony Ngo and Assistant Administrator Lara Langa who allowed the entry of the facility and also 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. The facility is vendored as Level 3 home with San Gabriel Pomona Regional Center 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 has an updated infection control plan and the facility continue to practice hand washing and disinfecting the facility each shift and The facility has sufficient PPE supplies in the facility. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: kitchen, living room, dining area, three client's bedrooms, one client bathroom, a staff break room, live in staff room with bathroom and attached garage but used as a storage room. Bedroom#1 and #3 has one bed, one chair, one drawer, required beddings and furniture and sufficient lighting and closet space. Bedroom#2 has two beds, chair, two drawers, required beddings and furniture and sufficient lighting and closet space. The client's bathroom is clean, sanitary and in a good working condition. The hot water tested at the client bathroom and kitchen are between 105.6 and 112.1 degrees F which is within the Title 22 regulation. All the kitchen appliances are working properly. The sharp knives and utensils are stored in the garage. The cleaning supplies and chemicals are stored and locked in the garage. The extra personal hygiene products are stored and locked in the garage cabinet. The hallway light will be on during night time for client to have access the non-private bathroom. The facility has a telephone on premises. LPA inspected the carbon monoxide detectors and it's near the kitchen and it's working well.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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 3

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: 05/16/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

3. Operational Requirement: The facility is approved for 6 non-ambulatory of which 2 maybe non-ambulatory. Currently all the clients in the facility are ambulatory. The facility has a covered patio with table and chairs for client to utilize the outdoor activity. The facility would also allow client to attend the community activities if there's a chance or opportunity.

4. Staffing: Facility has sufficient staffing in the facility. The NOC shift staff has the planned emergency procedure training.

5. Personal Records-Training: All the staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. All the facility staff has the required documents in files which include: required training hours, Health screening, TB Test result and updated First Aid Certificate. The facility administrator is Anthony Ngo and administrator certificate 11/3/2025 and he has the updated HIV and TB training certificate

6. Client's Right-Information: Currently the facility has no client with any postural support. The facility served internet service and provided at least one internet access device that can support real time interactive application for client to have video conferencing with their family or physician if needed.

7. Food Service: The facility has sufficient food supply including minium 2 days perishable and 7 days non-perishable. The facility kitchen is clean and well kept and in a operable condition. The food are properly stored in the refrigerator to avoid cross contamination. No resident required a modified diet that's prescribed by the doctor.

8. Client Record-Incident Reports: The client's files are stored in the file cabinet near the staff break room. LPA inspected all four clients' files and they all have the required documents which include: face sheet, admission agreement, functional capability assessment, Individual Program Plan (IPP), updated medical and dental assessment, ambulatory status and medication list.

9. Health Related Services: The facility medication is centrally stored and locked in the cabinet near the dining area. LPA inspected all four client's medication and they all seemed accurate and updated and they all have 30 days supply of medication.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 05/16/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

10. Incident Medical and Dental: Currently there's no client with any Restricted Health condition or Prohibited Health Condition.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D). The facility has two appropriate alternative shelter location. The last fire and earthquake drill was conducted on 3/5/2024. The emergency exit plan and telephone number posted on the wall near the dining area

12. Emergency Intervention: Facility does not use any restraints on clients.

No deficiencies were observed during the visit

Exit Interview conducted and a copy of the report was provided to Lara Langa

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3