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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004010
Report Date: 05/01/2025
Date Signed: 05/01/2025 11:39:54 AM

Document Has Been Signed on 05/01/2025 11:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LE-NA'RESIDENTAL CARE, INC.FACILITY NUMBER:
306004010
ADMINISTRATOR/
DIRECTOR:		LEONA SMITHFACILITY TYPE:
735
ADDRESS:5521 LOCKHAVEN DRIVETELEPHONE:
(714) 670-8397
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
05/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Avolie Rhaburn TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA informed Caregiver (CG) Avolie Rhaburn the purpose of the visit. CG informed Administrator (AD) Leona Smith that LPA was present and AD granted CG permission to assist LPA with the annual inspection. The facility currently has six clients of which three are out of the facility.

The facility is a one story home with three client bedrooms, one staff bedroom, two bathrooms, a kitchen, living room, dining room, laundry room, detached two car garage, and backyard. Facility appears clean, safe, and sanitary. LPA observed the kitchen to be free of debris. LPA observed the knives to be locked in a cabinet located in the kitchen inaccessible to clients in care. LPA observed a two day perishable and seven day non-perishable food supply on hand. LPA observed toxins to be locked under the sink and in a cabinet in the backyard making them inaccessible to clients in care. Client bedrooms had all the required components and furnishings. LPA observed bathrooms to have soap, toilet paper, hand drying machines, and textured flooring in the showers. LPA measured hot water in client bathrooms to be 114.0 degrees Fahrenheit in the bathroom located closest to the kitchen and 109.2 degrees Fahrenheit in the bathroom by the laundry room. LPA observed the centrally stored medication to be locked in a cabinet located in the living room and made inaccessible to clients in care. LPA observed the staff bedroom to be locked and made inaccessible to clients in care. LPA observed the garage to be locked making it inaccessible to clients in care. LPA observed the emergency food and water supply to be located in the garage. LPA observed extra food storage located in the garage. LPA observed the backyard to be free of debris and obstructions. LPA observed a shaded seating area for client use in the backyard.

Continue on 809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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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Document Has Been Signed on 05/01/2025 11:39 AM - It Cannot Be Edited


Created By: Hanna Gough On 05/01/2025 at 10:59 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'RESIDENTAL CARE, INC.
FACILITY NUMBER: 306004010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one staff file not having a health screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licensee stated that they will obtained a health screening and email to LPA by POC due date.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in completing an emergency drill which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licensee stated that they will conduct an emergency drill and send proof to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LE-NA'RESIDENTAL CARE, INC.
FACILITY NUMBER: 306004010
VISIT DATE: 05/01/2025
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LPA reviewed client files and no discrepancies were observed. LPA reviewed client medications and no discrepancies were observed. LPA reviewed P&I with CG and no discrepancies were observed. LPA did not observed an emergency disaster drill. LPA reviewed staff files and one staff did not have a health screening. All staff present have been background cleared and are associated to the facility.

Based on observations, record review, and interviews during today’s inspections deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Caregiver Avolie Rhaburn and a copy of this report, LIC 809-D and appeal rights were given at the time of inspection.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
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