Lejenz Home Care II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 year continuation inspection using the full Care Compliance and Regulatory Enforcement (CARE) Tools. Upon arriving at the facility, LPA met with Administrator / Jennifer Leon who assisted with the visit. LPA explained the purpose of this visit. The facility is licensed to serve for a capacity of six (6) Residents ages 60 and over. The facility has an approved fire clearance for five non-ambulatory residents and one bedridden resident, designated to room #4. Hospice care waiver approved for six (6) residents. Currently, there are six (6) residents in placement. There is one (1) bedridden resident and four (4) residents receiving hospice services. The facility has an approved Dementia Care plan as part of its plan of operation and accepts/cares for residents with dementia. During the initial Required - 1 Year inspection conducted on 6/2/23, LPA Katrdzhyan observed and reviewed the following (CARE) tool domains: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Food Service and Health Related Services/Incidental Medical & Dental. As part of today's inspection, LPA observed and reviewed the remaining (CARE) tool domains: Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Planned Activities, Disaster Preparedness and Residents with Special Health Needs. Personnel Records/Staff Training: Administrator's Certificate is current and expires on 8/8/2024. Staff have criminal background clearance and training. A random selection of staff files were reviewed. First Aid/CPR training, Personnel Record, Health Screening, Criminal Record Statement, Employee Rights and Staff Training. Resident Records/Incident Reports: A random selection of resident files were reviewed. Admission Agreement, Physician's Report, Consent Forms, ID & Emergency Information, Appraisal & Needs Service Plan, Immunization/TB clearance, Centrally Stored Medication Destruction Record, Safeguards for Property Valuables and Personal Rights. The Incident report binder was reviewed. Resident Rights/Information: RCFE complaint poster and Personal rights were observed posted. Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints was posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in a centralized location. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: One (1) resident is receiving home health services. There is one (1) bedridden resident and four (4) residents receiving hospice services. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. No deficiencies were observed during this visit. An exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 8, 2023

Type of visit: POC

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Plan Of Correction (POC) visit to follow up on the deficiencies issued during the Required - 1 Year inspection conducted on 6/2/23. Upon arriving at the facility, LPA met with Administrator / Jennifer Leon who assisted with the visit. The purpose of this visit was explained. On 6/2/23, the facility was cited for: 87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. On 6/2/23, LPA observed a discrepancy on the labels listed on two bottles of the same medications and the instructions listed on the Medication Administration Record (MAR) for Carbidopa-Levodopa 25/100mg. Bottle 1 of Carbidopa-Levodopa 25-100 Tab states, take 2 tablets by mouth 5 times daily. Bottle 2 of Carbidopa-Levodopa 25/100mg states, take 2 1/2 tablets by mouth 5 times daily. According to the Medication Administration Record states, staff are administering the medication by administering "3 tabs PO QID" (four times daily). POC: On 6/2/23, LPA received a Physician's order for Carbidopa-Levodopa 25/100mg matching the instructions listed on the MAR "Take 3 tabs 4 times per day". Deficiency is cleared and no further action is needed. 87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. On 6/2/23, LPA observed an empty bottle of FOCUS CBD 25MG CBD gummies (chew 1 gummy PO QD (take once a day) and a new bottle with a refill was not available at the facility. POC: On 6/2/23, LPA received a Physician's order discontinuing the FOCUS CBD 25MG CBD gummies/ Deficiency is cleared and no further action is needed. 87705(h) Care of Persons with Dementia Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. On 6/2/23, LPA observed the exit gate located on the left side of the property facing the street is not enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. The self closing mechanism/latch on the exit gate located on the right side of the property facing the street, is inoperable and does not self close. During today's visit, LPA observed self closing latches were installed on both exit gates and the exit gates were tested and operational at the time of visit. Deficiency is cleared and no further action is needed. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 8, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. Upon arriving at the facility, LPA met with Administrator / Jennifer Leon who assisted with the visit. LPA explained the purpose of this visit. The facility is licensed to serve for a capacity of six (6) Residents ages 60 and over. The facility has an approved fire clearance for five non-ambulatory residents and one bedridden resident, designated to room #4. Hospice care waiver approved for six (6) residents. Currently, there are six (6) residents in placement. There is one (1) bedridden resident and four (4) residents receiving hospice services. The facility has an approved Dementia Care plan as part of its plan of operation and accepts/cares for residents with dementia. The following (CARE) tool domains were observed and reviewed during today's visit: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Food Service and Health Related Services. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility is encouraging hand washing and self symptom check of staff and visitors. Each client bedroom is designated as a COVID-19 isolation room if needed and will use the closest restroom. Physical Plant/Environment Safety: The facility is a single story home located in a residential area which consist of 2 living rooms, a kitchen, dining room, 5 resident bedrooms, 2 staff bedrooms, 2 bathrooms, a sun room/office, an attached garage/laundry area/storage and a backyard. No large bodies of water were observed. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients. Water temperature readings were measured between the required 105 - 120 degrees Fahrenheit. The attached garage is kept locked and inaccessible to residents at all times. The facility has a Fire pull alarm located in the living room (near the main entrance). The exit gate located on the left side of the property facing the street is not enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. The self closing mechanism/latch on the exit gate located on the right side of the property facing the street, is inoperable and does not self close. The auditory chimes located on the exit doors in rooms 2 and 6 were observed to be inoperable. Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for five non-ambulatory residents and one bedridden resident, designated to room #4. Care and supervision to meet the clients needs was observed. No Surety bond is in place. Facility does not handle resident monies. During today's visit, LPA was unable to verify the coverages listed on the Liability of Insurance as the facility renewed the policy effective 6/1/23 and a copy of a current Certificate of Liability Insurance has not been provided by the insurance carrier to the facility. LPA spoke with Licensing Program Manager Tony Vasallo, and was advised to obtain the renewal paperwork so that LPA Cynthia Chan can follow up with the Administrator. The Administrator was asked to provide a current copy of the Certificate of Liability Insurance to CCL within one week (6/9/23). No deficiency is issued today, per LPM Tony Vasallo. Staffing: A total of ten staff members provide care and supervision to the clients. Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Health Related Services: Clients are assisted with self administration of prescription and non-prescription medications. A random selection of resident medication records were reviewed. Centrally stored medications are kept in the closet located in the living room area (near the entrance door) and kept locked and inaccessible to residents in care. During today's visit, LPA observed a discrepancy on the labels listed on two bottles of the same medications and the instructions listed on the Medication Administration Record (MAR) for Carbidopa-Levodopa 25/100mg for Resident 1 (R1). Bottle 1 of Carbidopa-Levodopa 25-100 Tab states, take 2 tablets by mouth 5 times daily. Bottle 2 of Carbidopa-Levodopa 25/100mg states, take 2 1/2 tablets by mouth 5 times daily. According to the Medication Administration Record states, staff are administering the medication by administering "3 tabs PO QID" (four times daily). During today's visit, LPA observed an empty bottle of FOCUS CBD 25MG CBD gummies (chew 1 gummy PO QD (take once a day) for R1 and a new bottle with a refill was not available at the facility. Per California Code of Regulations, Title 22, deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 2, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food, and medication review. LPA Flores met with Jennifer Leon administrator and explained the reason for the visit. The facility is licensed to served 6 non-ambulatory residents over the age of 60; of which 1 may be bedridden in room #4. Hospice waiver for 6 residents. The facility is a single story house located in a residential area which consist of a 2 living rooms, attached garage/laundry area/storage, kitchen, dining area, 5 resident bedrooms, 2 staff bedrooms, 2 bathrooms and a sun room/office, a backyard. No large bodies of water were observed. LPA Flores conducted a tour of the facility and observed the following: Living room has a covered fireplace, screening is conducting upon entry and it's located by the living room, medication closet was locked and located next to exit door. Kitchen was observed with sharps, and cleaning supplies locked. Sufficient food was observed for at least 2 days worth of perishables and 7 days of non perishables. All bedrooms have sufficient lighting, furniture and bedding supplies. Bathrooms have skid mats and grab bars, cleaning supplies were observed under each sink and locked, water was tested as follow; in bathroom #1 water tested at 110.5 degrees F., and bathroom #2 water tested at 114.2 degrees F., which is within the required 105 - 120 degrees F. Auditory devices were observed and in working condition in each exit door. Smoke detectors were tested and in working condition. Fire extinguishers were observed in kitchen and garage and are up to date. LPA Flores reviewed 6 residents medications and files and 3 staff files. Facility is following COVID 19 recommendations. A technical advisory has been given for N95 Fit testing. No deficiencies were given during this visit under Title 22 Regulations. Exit interview was conducted with Jennifer Leon administrator and a copy of this report and advisory note were provided.the state’s words, verbatim · CDSS document, Apr 25, 2022

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.