198602418-9-25-2020-28-AS-MVAO-BXNN42-20210127090710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 09/22/2020
Date Signed: 09/25/2020 11:12:10 AM

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
01/15/2020 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200115161409

FACILITY NAME:	HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTH		FACILITY NUMBER:	198602418
ADMINISTRATOR:	OGBECHIE, BIOSEH O		FACILITY TYPE:	740
ADDRESS:	120 S MYRTLE AVE		TELEPHONE:	(213) 478-0739
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	80	CENSUS: 41	DATE:	09/22/2020
		UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Lupe Harvey, Facility Manager		TIME COMPLETED:	01:18 PM

ALLEGATION(S):

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Staff caused injuries to residents while in care
Staff do not prevent residents from being harmed by other residents
Staff is not ensuring residents are properly fed
Staff is providing unsafe liquid for residents to consume
Staff is not properly trained to handle a resident with oxygen administration
Staff mishandled resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint investigation for the allegations listed above. 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 Harvey, the facility manager.

LPA Vasallo conducted the initial complaint visit on 1/17/20. During the initial visit, interviews were conducted with 9 staff and 5 residents. The physical plant was toured including the kitchen, common areas and residents’ bedrooms. Video call was used today to interview 2 staff, 2 residents and review medications.

Allegation: Staff caused injuries to residents while in care. It’s alleged Staff #1 (S1) slapped the hand of Resident #1 (R1). Residents interviewed had no knowledge of this allegation. Residents interviewed stated they were comfortable at the facility. 8 out of the 9 staff interviewed indicated they have not witnessed any injuries to residents caused by staff. Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200115161409

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: 09/22/2020

NARRATIVE

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1 staff member indicated he/she witnessed S1 slap the hand of R1. R1 did not corroborate the allegation. The physical plant was toured and there were no cameras observed. Based on information obtained, the allegation is unsubstantiated.

Allegation: Staff do not prevent residents from being harmed by other residents. Residents interviewed indicated they are comfortable in the facility and approved of the care being provided. Staff reported Resident #2 (R2) would hit and bite other residents. Staff stated they would separate the residents and keep the residents safe. Staff indicated the police were called one time because R2 was attacking staff. Police took R2 and R2 never returned. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff is not ensuring residents are properly fed. Residents interviewed indicated they were satisfied with the food. Staff interviewed indicated residents’ food is of good quality and is sufficient. During the initial visit, LPA toured the kitchen and observed lunch being served. There were no health and safety concerns and there was sufficient food observed. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff is providing unsafe liquid for residents to consume. Allegedly diabetics are being served sugary drinks. Residents interviewed did not corroborate the allegation. Staff interviewed denied the allegation and stated there are sugar-free drinks and other substitutes. LPA toured the kitchen and observed the pantry to have sugar-free sweeteners. There were also sugar-free or low sugar juices. The kitchen also had a list of diabetic residents for staff to reference. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff is not properly trained to handle a resident with oxygen administration. LPA toured the facility and interviewed residents. At the time of the investigation there was no evidence there were any residents using oxygen. Staff also denied any residents were using oxygen at the time of the investigation. The regulations state facility will ensure staff have knowledge of, and ability in the operation of the oxygen equipment. The training is not required unless residents are currently using oxygen. Facility manager was interviewed today and indicated there are no residents using oxygen. Based on the information obtained, the allegation is unsubstantiated.

Continued on 9099C.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20200115161409

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: 09/22/2020

NARRATIVE

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Allegation: Staff mishandled resident's medication. Residents were interviewed during the initial visit and subsequent visit. Residents indicated there have been no issues with medications. Some staff interviewed indicated they have heard complaints about medication, but did not know details. Other staff had no knowledge of medication issues. 5 residents' medications were reviewed today using video call. There were no discrepancies observed.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held with facility manager over the phone. Report was emailed to facility manager for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020

LIC9099 (FAS) - (06/04)

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