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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:55:40 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 HEALTHFACILITY NUMBER:
198602418
ADMINISTRATOR:OGBECHIE, BIOSEH OFACILITY TYPE:
740
ADDRESS:120 S MYRTLE AVETELEPHONE:
(626) 699-4613
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 33DATE:
09/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Staff / Jose Caringal
Facility Manager / Lupe Harvey		TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Noemi Galarza conducted an unannounced case management visit to this facility. Present during the visit were also, Licensing Program Manager / Adeline Ho, Rachel Tate and Nina Muller from the Long Term Care Ombudsman's Office (LTCO). During a Plan Of Correction (POC) visit conducted on 9/9/21, the following concerns were observed;
  • Upon arriving at the facility at 9AM, facility staff did not conduct temperature screenings for CCL and LTCO staff which poses an immediate health, safety or personal rights risk to persons in care.
  • At 10:33AM, LPA toured the second floor and observed the auditory chimes located on both exit doors (near rooms 35 and 32) leading to the patio deck were inoperable. The facility cares for residents with dementia and this presents an immediate health and safety concern for the residents in care.
  • At 10:42AM, LPA toured the kitchen/freezer and did not observe perishable foods for a minimum of two days. This presents an immediate health and safety concern for the residents in care.
  • During a tour of the facility, LTCO staff observed facility staff changing the diaper of R1 with the door open. This is a violation of privacy and personal rights of R1.
  • During a walk through of the physical plant (outside), LPA Galarza and LPM Adeline Ho observed a bed frame located on the walkway near the cottage. This poses a potential health and safety concern for the persons in care.

The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Facility Manager along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (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)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited

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(a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the
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State of California.
This requirement is not met as evidenced by:
Upon arriving at the facility at 9AM, facility staff did not conduct temperature screenings for CCL and LTCO staff which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/09/2021
Section Cited

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Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.


This requirement is not met as evidenced by;
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At 10:33AM, LPA toured the second floor and observed the auditory chimes located on both exit doors (near rooms 35 and 32) leading to the patio deck were inoperable. The facility cares for residents with dementia and this presents an immediate health and safety concern for the residents in care.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited

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General Food Service Requirements.
The following food service requirements shall apply: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by;
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At 10:42AM, LPA toured the kitchen/freezer and did not observe perishable foods for a minimum of two days. This presents an immediate health and safety concern for the residents in care.
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Type B
09/17/2021
Section Cited

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Personal Rights of Residents in All Facilities.
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...
This requirement is not met as evidenced by;
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During a tour of the facility, LTCO staff observed facility staff changing the diaper of R1 with the door open. This is a violation of privacy and personal rights of R1.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2021
Section Cited

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Personal Accommodations and Services.
The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by;
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During a walk through of the physical plant (outside), LPA Galarza and LPM Adeline Ho observed a bed frame located on the walkway near the cottage. This poses a potential health and safety concern for the persons in care.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4