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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603447
Report Date: 05/30/2025
Date Signed: 05/30/2025 02:21:09 PM

Document Has Been Signed on 05/30/2025 02:21 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:LEMON TREE HOME LIVINGFACILITY NUMBER:
198603447
ADMINISTRATOR/
DIRECTOR:		NGO, ANTHONY PA-CFACILITY TYPE:
735
ADDRESS:19328 BAELEN STREETTELEPHONE:
(626) 269-0822
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 4DATE:
05/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Anthony Ngo, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Daniel Konishi 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:

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.

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 107.6- and 107.7-degrees F which is within the Title 22 regulation. All the kitchen appliances are working properly. The sharp knives are locked in the kitchen drawer and inaccessible to clients.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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: LEMON TREE HOME LIVING
FACILITY NUMBER: 198603447
VISIT DATE: 05/30/2025
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Physical Plant and Environmental Safety: 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 nighttime for client to have access the non-private bathroom. Fireplace is closed, secure, and inaccessible to clients. Two (2) fire extinguishers are fully charged and last inspected on 01/28/2025. The facility has a telephone on premises. LPA inspected the carbon monoxide detectors and it's near the kitchen and it's working well.

Operational Requirement: The facility is approved for six (6) non-ambulatory of which two (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.

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

Personal Records-Training: LPA reviewed four (4) staff files and all four (4) staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. All four (4) staff has the required documents in files which include required training hours, Personnel Records, Health screening, TB Test result, Employee Rights, 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.

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.

Food Service: The facility has sufficient food supply including minimum 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.

Client Records-Incident Reports: The client's files are stored in the file cabinet near the staff break room. LPA inspected all four (4) clients' files and they all have the required documents which include: face sheet, admission agreement, functional capability assessment, Individual Program Plan (IPP), personal rights, ambulatory status, TB clearance, and medication list.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LEMON TREE HOME LIVING
FACILITY NUMBER: 198603447
VISIT DATE: 05/30/2025
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Health Related Services: The facility medication is centrally stored and locked in the cabinet near the dining area. LPA inspected all four (4) client's medication and they all seemed accurate and updated and they all have 30 days’ supply of medication. Facility has First Aid Kit with all required items.

Incidental Medical Services: Currently there's no client with any Restricted Health condition or Prohibited Health Condition.

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 03/03/2025. The emergency exit plan and telephone number posted on the wall near the dining area

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

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit Interview conducted and a copy of the report with appeal rights were provided to the Assistant Administrator, Lara Marie Langa.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
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