306006167-6-14-2023-22-AS-LMAZ-CSSVAG-20230614161556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006167
Report Date: 06/14/2023
Date Signed: 06/14/2023 04:16:36 PM

Document Has Been Signed on 06/14/2023 04:16 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 INC		FACILITY NUMBER:	306006167
ADMINISTRATOR:	LEE, JAMIE		FACILITY TYPE:	735
ADDRESS:	6622 MOUNT RIPLEY DRIVE		TELEPHONE:	(657) 214-2932
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 5	DATE:	06/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	Jamie Lee		TIME COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to the facility to conduct a Required - 1 Year inspection. LPA was greeted and granted entry by staff Nauzzeon Hull. LPA met with Administrator (AD) Jamie Lee and stated the purpose of the visit. AD Lee has a current Administrators Certificate that expires on 10/07/2024. Two staff and one client were present during today's visit. Four clients are at Program.

The facility is a two story home with eight bedrooms and five bathrooms. The second floor has 1 bedroom and 1 bathroom and is for staff use only. The facility is licensed for a capacity of six: five (5) ambulatory clients and one (1) non ambulatory client. There are six client bedrooms, and two staff bedrooms.

LPA Martinez, along with AD Lee toured the facility. LPA observed all required postings at the entrance of the facility. The kitchen was clean and well organized. All knives and sharp objects are locked in a cabinet drawer and inaccessible to clients. 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 the garage and/or a cabinet right outside the kitchen. LPA Martinez observed a Fire Extinguisher was fully charged and last serviced on 04/20/2023. 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. 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 bathrooms was within regulatory requirements. 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 with refreshments for the clients. There is a locked shed in the backyard that is currently being used as an office and 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 is used to transport clients around.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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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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: 06/14/2023

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Linen and hygiene supplies is stocked to meet all clients in care. Emergency Phone Numbers and Exit Plan was in place. Fire drills are conducted quarterly and LPA verified last Fire Drill was conducted on 04/22/2023. Medications are centrally stored in a locked closet under stairway. Medications reviewed appear to have been dispensed accurately.

First-Aid Kit had all the required elements and Activity Supplies were observed and available. There is a working land line at the facility. The LIC610D, Emergency Disaster Plan is posted.

LPA reviewed five client files and one staff file. LPA interviewed one client and one staff. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client.

Based on observations made, no deficiencies were observed at this time in the areas evaluated. Copy of this report will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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