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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006167
Report Date: 07/03/2024
Date Signed: 07/03/2024 11:42:28 AM

Document Has Been Signed on 07/03/2024 11:42 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-SA RESIDENTIAL CARE INCFACILITY NUMBER:
306006167
ADMINISTRATOR/
DIRECTOR:
LEE, JAMIEFACILITY TYPE:
735
ADDRESS:6622 MOUNT RIPLEY DRIVETELEPHONE:
(657) 214-2932
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 0DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:Jamie Lee - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analysts (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator Jamie Lee who arrived a short time later and was present for the remainder of the of the visit.

During the inspection, LPA Haley observed all client bedrooms and bathrooms. All client bedrooms had the necessary elements and were in compliance with regulation guidelines.

Client bathrooms were clean and organized. Hot water temperatures were measured in the range of 105.6 degrees Fahrenheit and 107.9 degrees Fahrenheit. All grab bars were tightly secured to the wall. In the bathroom near the kitchen, hazardous items are locked in a cabinet.

In the kitchen knives and sharp objects are locked in a toolbox. The stove was clean and operational. A perishable food supply that meets regulation requirements was observed in the refrigerator and a non-perishable food supply that meets regulation requirements was observed in a pantry area near the refrigerator. A fire extinguisher was observed on the floor and a carbon monoxide detector is in the corner on a shelf.

The garage was clean, organized, free of clutter, and walkways were free of obstruction. There’s a washer and dryer in the garage, a large supply of adult diapers stocked on the shelves, cleaning supplies, and a supply of hygiene items stored in the garage. An extra refrigerator with an additional food supply, a deep freezer with a supply of food items, as well as an additional supply of non-perishable items was observed. Several gallons of water was and an extra-large fire extinguisher was observed in the garage.

The backyard was clean, organized, and walkways were free of obstruction. A shaded patio area with a table and chairs was observed.

Continued on LIC809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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 2
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-SA RESIDENTIAL CARE INC
FACILITY NUMBER: 306006167
VISIT DATE: 07/03/2024
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There’s a gaming/entertainment area for clients to enjoy under the shaded patio area. There’s a large shed in the backyard used as an additional office space, a conference room, and a storage area. No bodies of water were observed.

During the visit a staff record review was completed for 4 staff members including Administrator Lee, 4 of 5 client medications were reviewed, and all 5 client files were reviewed.

Smoke detectors, and carbon monoxide detectors tested operational. A fully charged fire extinguisher was observed in the kitchen and in the garage.

An emergency evacuation drill was conducted June 19, 2024, and will continue to be conducted quarterly for staff on each shift.

No deficiencies will be cited during today’s visit.

An exit interview was conducted, and a copy of this report was provided to Administrator Jamie Lee.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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