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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001425
Report Date: 04/15/2022
Date Signed: 04/18/2022 09:07:23 AM

Document Has Been Signed on 04/18/2022 09:07 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LE-NA' RESIDENTIAL INC.FACILITY NUMBER:
306001425
ADMINISTRATOR:LEONA LYNN SMITHFACILITY TYPE:
735
ADDRESS:19782 RANGER LANETELEPHONE:
(714) 963-9847
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 4CENSUS: 4DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Caregiver, Rochell AdolphusTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry into the facility by Caregiver Rochell Adolphus and observed the screening station in the entrance of the facility. LPA completed the Coronavirus 2019 (COVID-19) screening procedures and stated the purpose of the visit. Administrator (AD) has an Administrator's Certificate that expired on 03/23/2022.

At 8:35 AM, LPA toured the facility with Caregiver Adolphus. The facility is a single level structure and licensed for 4 ambulatory clients. Facility has 4 out of 4 clients in care and all clients appeared well taken care of. All residents' rooms had the required elements as well as restrooms stocked with hand soap/sanitizer. Hand washing signs are posted in the restrooms as well as the required department COVID-19 precautionary postings around the facility. LPA observed antigen test kits, bath supplies, and the First Aid Kit that had the required items in the hallway closet. Facility had ample supply of PPE and cleaning solutions locked as well as emergency food and water in the garage. LPA toured the kitchen and observed ample food supply LPA toured the exterior of the facility and observed the outside visitation area with the required furnishings under sufficient shading. LPA observed a backyard shed used as storage containing cans of paint, termite/ant treatment, and personal belongings. The door handle to the shed was unlocked and broken. The left side gate was not self-latching and loose. Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. The fire extinguishers were mounted and charged.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LE-NA' RESIDENTIAL INC.
FACILITY NUMBER: 306001425
VISIT DATE: 04/15/2022
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LPA observed 2 iPads in the living room and discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet services to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPAs reviewed the approved COVID-19 mitigation plan of the facility.

Based on the observations made during today's visit, deficiencies are being sited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and the LPA will follow-up with the corrections. An exit interview was conducted with the facility representative and a copy of the report was provided as well as a copy of appeal rights.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2022 09:07 AM - It Cannot Be Edited


Created By: Jessica Cho On 04/15/2022 at 10:42 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LE-NA' RESIDENTIAL INC.
FACILITY NUMBER: 306001425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81087(i)

The licensee shall ensure that items which could pose a danger if readily availabe to clients, includng but not limited to disinfectants, cleaning solutions, and poisons are stored where inaccessible to clients.
Deficient Practice Statement
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This requirement is not met as evidenced by: LPA opened the backyard shed which the door handle was unlocked and not operational and observed cans of paints and termite/ant treatment in area that was accessible to clients. This poses an immediate health and safety risk to persons in care.
POC Due Date: 04/16/2022
Plan of Correction
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Licensee agrees to repair the broken door handle and keep it locked at all times.
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:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/18/2022 09:07 AM - It Cannot Be Edited


Created By: Jessica Cho On 04/15/2022 at 11:09 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LE-NA' RESIDENTIAL INC.
FACILITY NUMBER: 306001425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)


The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licesee is also the administrator, all requirements for an administrator shall apply.
Deficient Practice Statement
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This requirement is not met as evidenced by: based on the interview and review of document, administrator does not have a current certificate.
POC Due Date: 04/29/2022
Plan of Correction
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The administrator will complete all requirements for Administrator's Certificate renewal and forward a copy of the Administrator's Certifcate when complete.
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:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


LIC809 (FAS) - (06/04)
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