198602418-9-9-2021-28-AS-JKAN-C6PTNZ-20210909145331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:53:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	OGBECHIE, BIOSEH O		FACILITY TYPE:	740
ADDRESS:	120 S MYRTLE AVE		TELEPHONE:	(626) 699-4613
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	80	CENSUS: 33	DATE:	09/09/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Staff / Jose Caringal Facility Manager / Lupe Harvey		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Noemi Galaraza conducted an unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction citation issued during the case management visit conducted on 7/16/2021. Present during the visit were also, Licensing Program Manager / Adeline Ho, Rachel Tate and Nina Muller from the Long Term Care Ombudsman's Office. LPAs also conducted a health and safety check during today's visit. The purpose of this visit was explained to Facility Manager / Lupe Harvey.

On 7/16/2021 the facility was cited for:

HSC §1569.605 - Licensee failed to submit plan of correction proof of liability insurance to CCL on POC due date July 19, 2021 5:00 pm. As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties were issued for period 9/1/21 - 9/9/21. Total of 9 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 900.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.

Deficiencies are cited per Health & Safety Code Sections 1569.605 and Title 22.

LPA explained the citations, civil penalty assessment, and appeal rights.

Exit interview was conducted with Facility Manager / Lupe Harvey. A copy of the report and appeal rights were provided. Manager signed the report stating "Appeal".

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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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