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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006167
Report Date: 08/19/2025
Date Signed: 08/19/2025 06:23:53 PM

Document Has Been Signed on 08/19/2025 06:23 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
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: 1DATE:
08/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:31 PM
MET WITH:Paula StablerTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

Structure:


There’s a total of 8 bedrooms, of which 6 are for client’s and two are for staff. There are four restrooms, of which 3 are for client’s and one is for staff. There’s a living room space, a dining space, a large back yard area with plenty of shaded areas and activities for the clients to enjoy, and a garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water measured in between 112.7 – 117.5 degrees F. Kitchen: 5 of 5 burners were operational on the gas stove, including the warmer in the middle of the stove. Sharps are kept locked in a kitchen cabinet inside a locked toolbox. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed. An additional supply of perishable food items was observed in additional refrigerators in the garage.
Client & Staff Files: Client and staff files are located in a locked cabinets right behind the desk in the staff office area.
File Review: 3 of 6 client files were reviewed during the visit, and three staff files were reviewed.

Medications/First-Aid Kit: Client medications are stored in a locked medication cabinet behind the staff office area.


Medication Review: 3 of 6 client medications were reviewed during the visit.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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 5
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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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: 08/19/2025
NARRATIVE
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Linens & Hygiene Supplies: Hygiene items were observed in the client bathrooms and an additional supply of hygiene items were observed in the garage.

Garage Area: The garage is clean and organized. The walkways were free of obstruction. A washer and dryer was observed. An emergency food and water supply was observed, as well as a supplu of incontinent care items and an additional hygiene supply.

Backyard/Exterior: The backyard is clean and organized. Walkways are free of obstruction. There's a locked storage shed with a supply of cleaning chemicals. Plenty of activities for the clients was observed including an arcade style basketball hoop, a traditional basketball court, a dart board, and a shaded patio area equipped with a television and couches.

Bodies of Water: None.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguisher was observed mounted on a wall in the laundry area near the dining room.

An emergency evacuation drill: Was conducted August 7, 2025. Evacuation drills are conducted monthly.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:


Several facility postings are posted on the postings board on the wall in the staff office area.

Additional Comments: During the visit, 3 of 6 client files were reviewed, 3 or 6 client P&I funds were counted, and medications were reviewed for 3 of 6 clients. 3 staff files were reviewed and 3 staff were interviewed during the visit. Due to time constraints, clients were not interviewed.

Deficiencies are being cited as a result of today’s visit.

An exit interview conducted, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/19/2025 06:23 PM - It Cannot Be Edited


Created By: Jerome Haley On 08/19/2025 at 03:52 PM
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-SA RESIDENTIAL CARE INC
FACILITY NUMBER: 306006167

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in 1 of 3 client medications records were not accurate. Bedtime medications for Client 1 were not administered as prescribed. LPA observed three bedtime medications dated August 18, sill in the bubble pack. According to the MAR, the meds were administered by staff, but the medications were not administered. This poses an immediate health and safety risk to clients in care. Photos were taken.
POC Due Date: 08/20/2025
Plan of Correction
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House Manager/Administrator will ensure all staff receive medication training and email LPA Haley the training certificates provided upon completion. Including certificate numbers and topics covered during the training. Also, a list of the staff person responsible for administering medications for each shift will be emailed to LPA Haley.
POC is due by the close of business on the POC due date (8.20.25).
Type A
Section Cited
CCR
80070(b)(14)
An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 of 3 client P& I ledgers were not accurately recorded. Client 2's ledger was in accurate with a charge that did not match the amount on the receipt for that purchase. This poses an immediate personal rights risk to clients in care. Photos were taken.
POC Due Date: 08/20/2025
Plan of Correction
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House Manager/Administrator will email LPA Haley an accurate P&I ledger for all six clients. Licensee will provide an in-service training on accurate recording and handling of clients valuables. LPA will be provide a breakdown of the topics covered during the training, the duration of the training, and a sign in sheet for all staff in attendance.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/19/2025 06:23 PM - It Cannot Be Edited


Created By: Jerome Haley On 08/19/2025 at 03:52 PM
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-SA RESIDENTIAL CARE INC
FACILITY NUMBER: 306006167

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 of 3 clients records that were reviewed, Client 1 did not have an completed physicians report. The report dated August 6, 2025 was missing the second page, and some information was incomplete, which posed a potential health and safety risk to client's in care.
POC Due Date: 08/21/2025
Plan of Correction
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House Manager/Administrator will ensure Clients 1's physician report is completed and the complete report will be emaied to LPA Haley by the close of business on the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
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