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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004010
Report Date: 08/01/2025
Date Signed: 08/01/2025 02:35:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2025 and conducted by Evaluator Hanna Gough
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250620095342
FACILITY NAME:LE-NA'RESIDENTAL CARE, INC.FACILITY NUMBER:
306004010
ADMINISTRATOR:LEONA SMITHFACILITY TYPE:
735
ADDRESS:5521 LOCKHAVEN DRIVETELEPHONE:
(714) 670-8397
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:6CENSUS: 6DATE:
08/01/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Leona SmithTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Facility staff did not administer client's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Leona Smith and discussed the purpose of the visit.

The investigation into the allegation Facility staff did not administer client's medication as prescribed revealed the following: During file review it was revealed that Client #1(C1) was admitted to the facility on April 25, 2021. C1 has a physician’s report dated January 20, 2023, stating that they cannot administer or store their own medication. LPA observed a preplacement appraisal dated March 25, 2024, that states that C1 needs medication assistance. LPA observed medication orders and the centrally stored medication list for C1 dating from September 2024 to May 2025. LPA observed a prescription for Fenofibrate 145mg to be taken daily after meals. LPA observed that C1 did not receive any doses of Fenofibrate 145mg between January 1st, through January 5th, 2025, LPA reviewed physician’s orders and the centrally stored medication list that C1 is to receive ear drops 6.5% of four drops in the left ear twice a day.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20250620095342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LE-NA'RESIDENTAL CARE, INC.
FACILITY NUMBER: 306004010
VISIT DATE: 08/01/2025
NARRATIVE
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LPA observed that in September 2024 C1 had not received any doses of their eardrops. In April 2025 C1 was given 1 dose of their ear drops for the entire month in the evening on April 1, 2025. LPA observed the MAR which reflected that the ear drops had not been given in May 2025. LPA observed the dosage change for Risperdal from 3mg to 2mg per physician’s orders starting April 1, 2025. LPA observed in May 2025 C1 was receiving both 3mg and 2mg of Risperdal.

During interviews 1 of 2 staff stated that C1 could not get their eye drops due to not all staff being able to sign off on the MAR. Staff #1(S1) informed LPA that according to the MAR it looks as if the medication was not given properly and that they are trying to catch up on the medication. S1 informed LPA that they are not sure what happened and why the medication was missed.

Based on observation, interviews, information gathered during the investigation, and review of all documents obtained, the preponderance of evidence standard has been met. Therefore, the above allegation is deemed SUBSTANTIATED. A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Leona Smtih and a copy of this report along with 9099-D, LIC811 and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250620095342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LE-NA'RESIDENTAL CARE, INC.
FACILITY NUMBER: 306004010
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2025
Section Cited
CCR
80075(5)(B)
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Health Related Services 80075(5)(B)
Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidence by:
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Licensee stated they will have an in-service training on medication and a policy update sent to LPA by POC due date.
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Based on interviews and record review the licensee did not ensure C1 received all doses prescribed according to the physician's orders once ordered by the physician. This poses an immediate health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3