<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603140
Report Date: 09/09/2023
Date Signed: 09/09/2023 01:34:24 PM

Document Has Been Signed on 09/09/2023 01:34 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LEJENZ HOME CAREFACILITY NUMBER:
198603140
ADMINISTRATOR:LEON, JENNIFER MANABATFACILITY TYPE:
740
ADDRESS:384 S ROCK RIVER RDTELEPHONE:
(909) 895-7199
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 5DATE:
09/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Jennifer LeonTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 09/09/2023. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Administrator Jennifer Leon arrived shortly after. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents and is allowed to care for six (6) residents. The facility currently has an approved hospice waiver for six (6) residents.

LPA OBSERVATIONS: Tour was led by Administrator Leon. The facility is located on a residential street and is a single-story dwelling.

Front Yard: Was clean and well maintained. No hazards were observed. LPA Ramirez observed PPE supply station upon entry to the facility.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed fully charged fire extinguishers in this area. LPA Ramirez observed baby camera monitor displaying live video of resident #1 (R1) in kitchen area.

Dining Room: Dining room was observed to be clean and contained plenty of seating.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1- 4: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting.

Bathrooms 1-2: Water temperatures were within 105- 120 degrees F. Bathrooms were observed to be clean and have required non-slip mats and grab bars in shower and near toilet.

Centrally Stored Medications: LPA Ramirez observed several medications carts to be locked during visit.

Backyard: LPA Ramirez observed side patio with seating for residents

Emergency Drills: Fire drill was last conducted on 7/13/23 and earthquake drill was conducted on 7/1/23.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LEJENZ HOME CARE
FACILITY NUMBER: 198603140
VISIT DATE: 09/09/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways. LPA Ramirez observed posted Emergency Disaster Plan.

Staff Personnel Files: Two (2) staff files were reviewed.

Resident Files: Five (5) residents files were reviewed.

No deficiencies are being cited today. Exit interview was conducted Administrator Leon and a copy of this report and appeals rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3