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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801658
Report Date: 03/13/2023
Date Signed: 03/13/2023 11:32:49 AM

Document Has Been Signed on 03/13/2023 11:32 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LE-NA' RESIDENTIAL #5FACILITY NUMBER:
425801658
ADMINISTRATOR:ESTELLA USHERFACILITY TYPE:
735
ADDRESS:1448 WEST CALLE MARGARITATELEPHONE:
(805) 287-9473
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 4CENSUS: 3DATE:
03/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Estella Usher, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted a Case Management visit to address the deficiencies noted during complaint control # 29-AS-20230124162800 investigation. LPA met with Estella Usher, Administrator and explained the purpose of the visit.

Based on the investigation conducted, after C1 had already eloped the morning of 1/20/2023, Staff 1 admitted to observing C1 in the kitchen with their hand on their teeth and then a can on their teeth. Interviews revealed S1 said they thought C1 was picking food out of their teeth, even though they were holding a can to their teeth. S1 did not provide any interventions or redirection of C1, and walked back to assist C2, leaving C1 unsupervised. S1 stated they came back to kitchen and C1 was hitting their tooth with the can. S1 asked what they are doing? What’s wrong with your teeth? Does it hurt? C1 replies, “you don’t think I can do it? I can pull out my teeth, I can pull out my teeth. Nothing is wrong, I’m going to pull it out.” S1 stated they think their questions were taken as a challenge. S1 stated they told C1 to go to their room and listen to music, again not providing C1 with adequate supervision after S1 observed C1 hitting their teeth with a can. The investigation revealed this incident happened in about 15 minutes. C1 had pulled out their tooth before moving into the home, and the Administrator was aware of that but it was not in C1’s Individual Service Plan. Although C1 did not require one on one supervision and does not need assistance with ADLs, adequate supervision was not provided after S1 witnessed C1 in the kitchen touching and hitting their teeth with a can, and redirected C1 to their room, where there was no supervision. Additionally, Technical Assistance is issued to ensure staff have adequate training to handle client behaviors and appropriately address them.

At 10:35 AM LPA Olson observed one staff and one consultant in the facility near clients not wearing a mask.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit Interview completed, copy of the report and appeal rights were emailed and printed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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Document Has Been Signed on 03/13/2023 11:32 AM - It Cannot Be Edited


Created By: Jeannette Olson On 03/13/2023 at 10:37 AM
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 #5
FACILITY NUMBER: 425801658

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2023
Section Cited
CCR
80078(a)

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80078(a) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidenced by:
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Administrator agreed to train all staff in crisis intervention and provide training records to CCL with name, dates, and topics covered by 3/20/23
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Based on interviews, the licensee did not comply with the section cited above when staff did not provide the care and supervision client 1 needed while in crisis, which posed a potential health, safety and/or personal rights risk to persons in care.
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Type B
03/20/2023
Section Cited
CCR87468.1

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87468.1 Personal Rights of Residents in All Facilities
...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by...
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Administrator agreed to train all staff in masking requirements and provide training records to CCL with name, dates, and topics covered by 3/20/23
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Based on LPA observation, the licensee did not ensure staff were wearing face masks in the facility, which poses a potential health, safety and personal rights risk to residents in care.
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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:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023


LIC809 (FAS) - (06/04)
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