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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004010
Report Date: 05/12/2023
Date Signed: 05/12/2023 10:00:09 AM

Document Has Been Signed on 05/12/2023 10:00 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'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: DATE:
05/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Avolie RhaburnTIME COMPLETED:
10:20 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason made an unannounced case management visit to the facility for the purpose of issuing deficiencies. LPAs met with Staff Avolie Rhaburn and discussed the purpose of this visit.

During the required annual inspection conducted on 3/29/23, LPA Gutierrez and LPA Mason observed an addition had been made onto the house, closing off an exit indicated on the facility sketch. Administrator (AD) Jamie Lee stated the facility did not obtain a new fire clearance to close off that exit, therefore the facility was found to be operating outside of its fire clearance and was cited under California Code of Regulations (CCR) 80020(a). The plan of correction was for AD to submit an LIC200 and new facility sketch to Community Care Licensing (CCL) to request for a new fire inspection by 3/28/23. As of 5/12/23, CCL has not received required documents. During today’s visit, AD was contacted by phone and confirmed no documentation has been submitted to CCL to obtain a new fire clearance. A new deficiency is being cited per Title 22 Division 6 of the CCR.

LPAs conducted an exit interview and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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Document Has Been Signed on 05/12/2023 10:00 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/12/2023 at 09:36 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: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2023
Section Cited
CCR
80020(a)

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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
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Administrator (AD) Jamie Lee to submit an LIC200 with $25 check, and new facility sketch to CCL to a request for a new fire inspection by 5/15/23.
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based observation an addition has 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 to close off that exit, therefore the facility is operating outside of its fire clearance.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023


LIC809 (FAS) - (06/04)
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