198602418-9-2-2021-28-AS-MVAO-C75R3Y-20210923124044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 09/02/2021
Date Signed: 09/02/2021 09:57:35 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
02/14/2020 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200214114956

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: 35	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator, Lupe Harvey		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Facility staff is not properly trained.
insufficient staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with administrator, Lupe Harvey and explained the purpose of the visit. The initial complaint visit was conducted by LPA Rivas on 2/20/20. LPA Rivas conducted a subsequent visit on 2/27/20. LPA Vasallo conducted a subsequent complaint visit on 8/20/21.

The investigation consisted of the following: Interviews were conducted with 11 staff and 5 residents. Staff schedule was reviewed along with staff training records.

The investigation revealed the following: Allegation: Facility staff is not properly trained. On 8/24/21, administrator provided copies of caregiver and med tech training. It was discovered that Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) are caregivers and do not have the required 40 hour training on file. Staff interviewed indicated they have received some training, but could not confirm how many hours of training. Based on information obtained, the allegation is substantiated. Continued on 9099C.

Substantiated

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: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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-20200214114956

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: 09/02/2021

NARRATIVE

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Allegation: Insufficient staff. A total of 11 staff were interviewed during the multiple visits made. 6 out of the 11 staff interviewed indicated the facility is short staff. Staff reported working “double shifts” due to the lack of staff. Staff reported that the morning shift has 3 caregivers and would need additional staff to adequately supervisor residents. Staff reported at least 1 resident has wandered away from the facility and was found outside the facility unsupervised. Staff stated additional staff are needed in the morning since the morning staff are responsible for bathing, laundry and serving meals as well as assisting residents with activities of daily living. 4 out of the 5 residents interviewed indicated the facility is short staff. Residents report that caregivers have too many duties in the morning to properly assist residents. Residents report that staff do not respond promptly to the emergency pendant. Some residents reported waiting 45 minutes for staff to respond. LPA tested a resident’s pendant during the 8/20/21 visit. The resident was interviewed for approximately 15 minutes and staff did not respond. LPA returned to that resident’s room after the interview to ask if staff responded to the pendant. Resident indicated staff responded approximately 1 hour later. Based on information obtained, the allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 3.2 are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report and appeal rights were provided to Lupe Harvey.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200214114956

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: 09/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/03/2021 Section Cited HSC 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required....	1 2 3 4 5 6 7	Facility will provide a staffing plan that will explain how the needs of the residents will be met. Plan will be submitted by 9/3/21.
	8 9 10 11 12 13 14	Deficiency was evidenced by the following: 6 out of the 11 staff interviewed indicated the facility is short staff. Staff reported working “double shifts” due to the lack of staff. Caregivers also have to do laundry, serve meals and assist residents with bathing. 4 out of the 5 residents confirmed facility is short staff.	8 9 10 11 12 13 14
Type B 09/10/2021 Section Cited HSC 1569.625(b)(1)	1 2 3 4 5 6 7	Staff training; legislative findings; contents The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training.	1 2 3 4 5 6 7	Facility will provide a training plan to meet the requirements for all staff training. Plan will be submitted by 9/3/21.
	8 9 10 11 12 13 14	Deficiency was evidenced by the following: Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) are caregivers and do not have the required 40 training on file.	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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

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