198602418-6-24-2021-28-AS-MVAO-C75MSF-20210923095153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 06/24/2021
Date Signed: 06/24/2021 02:44:42 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
06/18/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210618123441

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: 31	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Lupe Harvey		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Residents are mistreated and abused by staff.
Facility does not adequately supervise residents.
Staff members yell at residents.
Staff members handle residents in a rough manner.
Facility food is not adequate for residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz conducted a complaint visit to investigate the allegations listed above. LPA met with Administrator, Lupe Harvey and discussed the reason for todays visit.

The investigation consisted of the following: LPA interviewed Administrator, Staff #1-4, and Resident #1-5. LPA toured the kitchen and food. LPA also requested copies of Staff and Resident Rosters, training records, and food menu.

The investigation revealed the following: It was alleged that staff members were abusing and mistreating residents. Based on interviews conducted with staff and residents, no one has seen or has been mistreated/abused. LPA did not see any signs of abuse on residents.
(continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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 5

Control Number 28-AS-20210618123441

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: 06/24/2021

NARRATIVE

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Regarding the allegation of the facility not adequately supervising the residents, although interviews indicated the night shift staff are not as attentive and fast as the day shift, the residents indicated their needs are being met. LPA also inquired about residents falling and not being helped. All interviews conducted revealed all the falls they have had are addressed and residents are assisted immediately.

It was alleged staff members yell at residents. Interviews conducted revealed there is a staff member who seems to get frustrated with 2 residents that are constantly yelling. Interviews revealed although the Caregiver seems to get frustrated, the caregiver does not raise her voice and does not curse at residents.

Regarding the allegation of staff members handling residents in a rough manner, interviews conducted with staff stated they have never seen or heard of a staff member handling a resident in a rough manner. One (1) out of Five (5) residents indicated staff are rough while assisting them.

It was alleged the food the facility serves was not adequate for residents in care. Interviews conducted with staff and residents revealed they serve a balance meal and residents have different options/alternatives when they do not like what is being served. LPA toured the kitchen and seen plenty of food. LPA was also provided with food menus of meals served and was there during lunch time and observed lunch being served.

Based on LPA's interviews conducted, observations and records reviewed, investigation revealed: 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 above allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with the Administrator and a hardcopy was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
06/18/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210618123441

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: 31	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Lupe Harvey		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility has pests.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz conducted a complaint visit to investigate the allegation listed above. LPA met with Administrator, Lupe Harvey and discussed the reason for todays visit.

The investigation consisted of the following: LPA interviewed Administrator, Staff #1-4, and Resident #1-5. LPA toured the kitchen and food. LPA also requested copies of Staff and Resident Rosters, training records, and food menu.

The investigation revealed the following: It was alleged the facility has a pest issue and had rats. Interviews conducted with staff and residents revealed some of them had seen at least (1) rat in the facility. LPA and Administrator observed several dropping in the entrance of the kitchen and by the door of the basement in the kitchen. LPA also observed several rat traps in the kitchen. (Continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20210618123441

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: 06/24/2021

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	Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations Title 22. Please see LIC 9099D An exit Interview was conducted with the Administrator and a hardcopy was provided . Appeal Rights was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210618123441

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: 06/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/02/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 (a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility will ensure they have a contract through a Pest Control company for pest control where the exterminator visits the facility monthly for inspections/treatments in order to eradicate the pest problem. Administrator will ensure that a visual inspection is conducted in ALL the facility and
	8 9 10 11 12 13 14	During the kitchen tour, LPA and Administrator observed rat/mice droppings in the entrance of the kitchen and by the door of the basement which is located in the facilities pantry.	8 9 10 11 12 13 14	a PLAN OF ACTION will be also submitted to CCLD documenting how the facility will ensure that the facility and including common areas are free from pest issues by POC due date.
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	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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5