306004010-3-27-2023-22-AS-CGUZ-CQBU5W-20230327151726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004010
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:17:43 PM

Document Has Been Signed on 03/27/2023 03:17 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	LE-NA'RESIDENTAL CARE, INC.		FACILITY NUMBER:	306004010
ADMINISTRATOR:	LEONA SMITH		FACILITY TYPE:	735
ADDRESS:	5521 LOCKHAVEN DRIVE		TELEPHONE:	(714) 670-8397
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY: 6		CENSUS: 6	DATE:	03/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jamie Lee		TIME COMPLETED:	03:35 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 Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by Staff Gian Pucan. LPAs discussed the purpose of the inspection and Administrator (AD) Jamie Lee was contacted by phone and arrived at the facility at 1:03 p.m.

During the inspection LPAs conducted a tour of the inside and outside of the facility, common areas, client rooms, staff room, kitchen, garage and observed the following:

This is a one-story house with three client bedrooms, two bathrooms, and two staff bedrooms. All client bedrooms had the required furnishings. LPAs observed all client beds had linens and blankets. LPAs observed all windows were screened. The back yard has a shaded sitting area. LPAs observed two staff and five clients present. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 119.1 F degrees.

LPA Gutierrez observed emergency disaster plan and emergency phone numbers listed and posted. Food menu was also posted and visible. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Sharps were observed to be inaccessible. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed to be locked. The first aid kit has all the required elements. LPAs reviewed three client files and three staff files. LPAs interviewed two clients and one staff.

During the inspection, LPAs observed that an addition had been made onto the house, closing off an exit indicated on the facility sketch. AD stated the facility did not obtain a new fire clearance designating the addition as a staff bedroom, therefore the facility is operating outside of its fire clearance. (Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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 3

Document Has Been Signed on 03/27/2023 03:17 PM - It Cannot Be Edited

Created By: Claudia Gutierrez On 03/27/2023 at 02:30 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
, 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and admission, the licensee did not comply with the section cited above by building an additional bedroom onto the house without required fire clearance, which poses an immediate health, safety or personal rights risk to persons in care
	POC Due Date: 03/28/2023
	Plan of Correction
1 2 3 4	AD stated they will submit a new facility sketch and a request for a new fire inspection to approve addition as a staff bedroom by 3/28/23. AD stated they submit the new facility sketch and fire clearance to their LPA once they have been approved.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Claudia Gutierrez

LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LE-NA'RESIDENTAL CARE, INC.	FACILITY NUMBER: 306004010
	VISIT DATE: 03/27/2023

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

AD stated they will submit a new facility sketch and a request for a new fire inspection to approve addition as a staff bedroom by 3/28/23. AD stated they will submit the new facility sketch and fire clearance to their LPA once they have been approved.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and. appeal rights was left at the facility

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3