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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 11/03/2020
Date Signed: 11/03/2020 04:32:24 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2020 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20200210142745
FACILITY NAME:HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTHFACILITY NUMBER:
198602418
ADMINISTRATOR:OGBECHIE, BIOSEH OFACILITY TYPE:
740
ADDRESS:120 S MYRTLE AVETELEPHONE:
(213) 478-0739
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 42DATE:
11/03/2020
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Lupe Renee Harvey - Facility ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Flores conducted a subsequent visit to deliver findings regarding the above allegations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Lupe Renee Harvey Facility Manager.

The investigation consisted of the following: On 2/14/2020 LPA met with Karen Johnson - Regional Facility Operator and toured the Medication Room, interviewed residents #1, #2,#3,#4,#5,#6,#7,#8 (R1 - R8), reviewed the residents medication and medication sheets, and interviewed staff #1 and #2 (S1, S2). LPA requested copies of client and staff roster, Medication sheets for R1,R2,R3,R4,R5,R6,R7,R8 for the last three months. On 3/4/2020 LPA Flores conducted a subsequent visit and met with Karen Johnson Regional Facility Operator, toured the medication room and reviewed medication for residents #9,#10,#11,#12,#13, #14,#15,#16, requested a copy of the following documents: client and staff roster, Medication Sheets for R1 - R8 for the months of December, January, February, Medication Sheets for R9 - R18 for the months of January, February, and March. LPA reviewed staff #2 and #3's (S2,S3) files.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20200210142745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTH
FACILITY NUMBER: 198602418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2020
Section Cited
CCR
87465(e)(1-4)
1
2
3
4
5
6
7
Incidental Medical and Dental Care;For... PRN medication...there shall be a signed, dated...order from a physician,...a label... contain...all of the...information.1)specific symptoms...(2) exact dosage.(3)...hours between doses.(4)The maximum...doses allowed in each 24-hour period. This requirement is not met by:
1
2
3
4
5
6
7
Facility will provide training for staff from an independent pharmacy, submit copies of trainings, ensure that all PRN medication has a doctor's prescription, and LIC 9098 proof of correction by 11/4/20.
8
9
10
11
12
13
14
Based on observation and medication review, facility stored PRN medication for 5 out 16 residents (R2,R4,R6,R7,R8) without a prescription label or physician's order, which poses a immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type B
11/17/2020
Section Cited
HSC
1569.69
1
2
3
4
5
6
7
Employees assisting residents with self administration of medication; training requirements;a)...employee...meets... training requirements:1)... employee shall complete 24 hours of initial training...16 hours of hands on shadowing training,... 8 hours of... instruction... This requirement is not met as evidence by:
1
2
3
4
5
6
7
Facility will provide training for staff from an independent pharmacy and submit copies of trainings and LIC 9099 proof of correction by 11/17/20.
8
9
10
11
12
13
14
Based on observation and file review, facility did not ensure 2 out 2 staff obtained 16 hours of hands on and 8 hours of instruction training prior assisting residents with medication, which pases a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20200210142745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTH
FACILITY NUMBER: 198602418
VISIT DATE: 11/03/2020
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
The investigation revealed the following: Regarding allegation; staff are mismanaging resident’s medication, and that caregivers are not administering the medications correctly. During the visit of 2/14/20 and 3/4/20 LPA toured the Medication Room and observed that medication is kept in clear storage boxes which are labeled individually with each residents’ name and each residents’ medication is kept in it. Upon review of medication on 2/14/2020 and 3/4/2020 LPA observed 5 out of 16 residents’ who were taking over the counter medications (PRN) there is no label and/or the prescription physician’s order. Over the counter medications such as; glucosamine, vitamin B, Duoderm, Vitamin D3, Calmoseptine, Fish oil, Ointments, and Tylenol, were observed in medication box for R2,R3,R4,R6,R7. LPA took pictures of mentioned over the counter medications during the visit of 3/4/20. In 4 out of 16 residents, facility did not have a centrally store medication record for R5,R6,R7,R8 for prescribed and/or over the counter medications. When LPA inquired staff regarding physician’s prescription for PRN medication, staff stated that she was not aware as she is temporarily providing medication to residents. LPA did not observed a Medication sheet or centrally store medication record for 3 out of 16 residents, R2,R10,R11 were missing Medication Sheet/Centrally store medication record in the provided medication’s binders kept by the facility, when LPA asked S2 she was unable to provide a response by stating “I don’t know. I am not the Med Tech”. 13 out of 16 residents, R1,R3,R4,R5,R6,R7,R8,R9,R12,R13 were missing Medication sheets/Centrally store medication record for one or more months between December 2019 and March 2020. On 2/14/20 LPA observed medication belonging to 2 other residents whose medication was not being reviewed during the visit, were stored in R5 and R8’s medication storage boxes. Interviews with residents revealed that 3 out 16 residents had concerns regarding their medication being handle by different staff members within the last few months, as residents fear that caregivers might not have proper training and/or not be familiar with the medication each resident takes. On 2/14/20 staff was unable to provide copies of medication sheets, or trainings for facility’s staff due to file cabinet’s key missing. On 3/4/20 LPA reviewed S1 and S2 files and observed, S1 has 16-hour training on assisted living medication training program, 8 hours of initial instruction and 8 hours of hands-on shadowing dated 11/8/19. S2 has 5.42 hours of training relate to medication for residential care for the elderly.
Based on LPA’s interviews, medication, medication sheets reviewed, and observations conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED.

An exit interview was conducted with Facility Manager , and a copy of this report was email for signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20200210142745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTH
FACILITY NUMBER: 198602418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2020
Section Cited
CCR
87465(h)(6)
1
2
3
4
5
6
7
Incidental Medical and Dental Care;h)... medications... centrally stored 6)... responsible...record of... medications for each resident...: A) name...B) prescribing physician. C)... drug name, strength...quantity. D) ...date filled.E)... number and the name of the...pharmacy.F)... This requirement not met as evidence by:
1
2
3
4
5
6
7
Licensee will provide training for staff from an independent pharmacy, submit copies of centralize stored medication sheets for all 16 residents by 11/17/20.
8
9
10
11
12
13
14
Based on observation and medication sheet review, facility did not ensure staff recorded PRN for 4 out of 16 in medication sheet, for 13 out of 16 residents facility did not keep a medication sheet for one or more months, which poses a potential risk Health, Safety, or Personal Rights to the person in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4