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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006167
Report Date: 06/27/2022
Date Signed: 06/27/2022 12:05:48 PM

Document Has Been Signed on 06/27/2022 12:05 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-SA RESIDENTIAL CARE INCFACILITY NUMBER:
306006167
ADMINISTRATOR:LEE, JAMIEFACILITY TYPE:
735
ADDRESS:6622 MOUNT RIPLEY DRIVETELEPHONE:
(657) 214-2932
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 5CENSUS: 2DATE:
06/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Leona SmithTIME COMPLETED:
12:12 PM
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Licensing Program Analyst (LPA) Jerome Haley made an announced visit to this facility to conduct a pre-licensing inspection and Component III orientation. LPA was greeted and granted entry by staff and stated the purpose of the visit. LPA met with Administrator (AD) Leona Smith. AD Smith has a current Administrators Certificate that expires 3/23/24.

The facility is a two story home with eight bedrooms and five bathrooms. The upstairs portion (1 bedroom and 1 bathroom) of the facility is for staff use only. The facility is being licensed for a capacity of five: four ambulatory clients and one non ambulatory client. There are five client bedrooms, two staff bedrooms, and one bedroom is being used as an office.

At 10:10 am LPA Haley began the tour of the facility. LPA observed all required postings at the entrance of the facility. There is a screening station set up equipped with a temperature thermometer, hand sanitizer, and surgical mask. LPA Haley was screened before entering the facility.

The kitchen was clean and well organized. All knives and sharp objects are locked in a cabinet drawer and inaccessible to residents. The facility has a two day supply of perishable food items, a seven day supply of non perishable food items, and a variety of fruit available for the clients in care. All hazardous chemicals were locked in a cabinet right outside the kitchen. LPA Haley observed a fire extinguisher that was fully charged in the kitchen.

The garage was clean, organized and walkways were free of tripping hazards. LPA observed an a variety of food items and an emergency supply of water and food. LPA observed emergency bags and emergency kits prepared and ready to go for each client in care. There's an emergency supply of PPE supplied in the garage. LPA Haley observed an additional fire extinguisher in the garage that was fully charged.


Continued on 809-C Dated 6/27/22
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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-SA RESIDENTIAL CARE INC
FACILITY NUMBER: 306006167
VISIT DATE: 06/27/2022
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At 10:20 am LPA Haley and AD Smith began the tour of client rooms and bathrooms. All client bedrooms were clean, well organized, and equipped with all the necessary requirements: night stand, chair, lamp and storage space. Bathrooms were clean and sanitary. Hot water temperature in client bathroom #1: 105.5 degrees Fahrenheit and in Bathroom #2: 107.9 degrees Fahrenheit.

The backyard area was clean, organized free of clutter and walkways were free of tripping hazards. There's a shaded patio area with tables and chairs. There's a game room with a TV, entertainment, and a refrigerator full of refreshments for the clients to enjoy. There's a locked shed in the backyard that's currently being used for storage. There is a small area behind the shed, locked and inaccessible to clients, also being used for storage. There's a side exit gate that is self closing and self latching. The facility has clean and well maintained van parked in the backyard driveway that will be used to transport clients around.

On April 6th, 2022, The Orange County Fire Authority granted the fire clearance for, four ambulatory clients, and one non ambulatory client. During the visit the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.



The Pre-licensing is complete, Component III was waived and the facility does not need any corrections at this time. The license will be granted upon completion of a final review and approval by the Centralized Applications Bureau for final determination. An exit interview was conducted, and copy of this report was left with Administrator Leona Smith.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC809 (FAS) - (06/04)
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