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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801208
Report Date: 01/31/2022
Date Signed: 01/31/2022 02:24:17 PM

Document Has Been Signed on 01/31/2022 02:24 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LE-NA' RESIDENTIAL HOME #3FACILITY NUMBER:
425801208
ADMINISTRATOR:ESTELA USHERFACILITY TYPE:
735
ADDRESS:475 WILSON COURTTELEPHONE:
(805) 934-2167
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 4DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Yvette WrightTIME COMPLETED:
02:30 PM
NARRATIVE
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On 01/31/22 at 12:30 p.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced annual visit to the facility. LPA with Staff (S1) Yvette Wright and explained the purpose of the visit. The facility is an Adult Residential Facility with funding from Tri-Counties Regional Center.

At 12:35 p.m., LPA entered the kitchen and observed a fire extinguisher with the serviced tag marked Sep 15, 2020.
At 12:42 p.m., LPA entered the garage and observed a fire extinguisher with the serviced tag marked Nov 18, 2019.
At 1:20 p.m., LPA went over the Infection Control module and advised S1 that the facility will need to have staff fit tested with N95 when working with Covid-19 positive clients. Infection Control module was addressed with S1 to satisfaction.
LPA did not observe any other deficiencies.

LPA issued citation on LIC 809D, issued an immediate civil penalty for the amount of $500, conducted exit interview, provided appeal rights, and emailed report to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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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Document Has Been Signed on 01/31/2022 02:24 PM - It Cannot Be Edited


Created By: Toan Luong On 01/31/2022 at 02:04 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LE-NA' RESIDENTIAL HOME #3
FACILITY NUMBER: 425801208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) 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:
Deficient Practice Statement
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The facility did not have fire extinguisher serviced or purchased within a year. Based on observation, the licensee did not comply with the section cited above in 2 out of 2 count which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2022
Plan of Correction
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Facility will submit to LPA proof of receipt or fire extinguisher serviced by 2/1/22
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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Toan Luong
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


LIC809 (FAS) - (06/04)
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