<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 09/02/2021
Date Signed: 09/02/2021 10:00:24 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
02/19/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200219133957
FACILITY NAME:HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTHFACILITY NUMBER:
198602418
ADMINISTRATOR:OGBECHIE, BIOSEH OFACILITY TYPE:
740
ADDRESS:120 S MYRTLE AVETELEPHONE:
(213) 478-0739
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 35DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Administrator, Lupe HarveyTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was not provided a refund.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 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. LPA obtained checks made out to the facility and Resident #1's (R1) physician's report.

The investigation revealed the following: It’s alleged R1’s responsible party was not provided a refund after leaving the facility. R1 was allegedly a resident of the facility for 1 week in February 2019. R1 was moved after R1’s responsible party was unhappy with the care being provided to R1.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (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)
Page: 1 of 5
Control Number 28-AS-20200219133957
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
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
Current administrator could not locate R1’s file. R1’s responsible party claims they were never given a copy of the admission agreement. R1’s responsible party provided LPA with a copy of R1’s physician’s report dated 1/31/19. The facility’s name and address is listed on the physician’s report. Facility was cited on a previous case management visit for not having R1’s file at the facility. On 8/23/21, administrator confirmed that the corporate office did have R1 listed as a previous resident but did not have a move out date. The current administrator was not the administrator in 2019.

LPA obtained checks from R1’s responsible party. The checks are made out to Henrietta’s Leven Oaks. Check dated 2/1/19 was made out for $1,500. Check dated 2/2/19 was made out for $3,250. R1’s responsible party reported the checks were cashed. Facility confirmed R1 was a previous resident of the facility and complaint alleges resident was only at the facility 1 week. R1’s responsible party was not provided with a copy of the admission agreement. Facility could not locate R1’s file which facility is required to have. Facility does not have documentation that would exclude them from providing a refund. Therefore, R1’s responsible party would be entitled to a pro-rated refund for payments made for the month of February 2019 and preadmission fees. Based on the information obtained, the allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (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)
Page: 2 of 5
Control Number 28-AS-20200219133957
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 B
09/10/2021
Section Cited
CCR
87507(g)(5)(A)
1
2
3
4
5
6
7
Admission Agreements
Admission agreements shall specify the following: Refund conditions. Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Heath and Safety
1
2
3
4
5
6
7
Administrator indicated the corporate office will be contacting R1's responsible party to discuss the refund. Facility will submit proof the refund was provided to R1's responsible party.
8
9
10
11
12
13
14
Deficiency was evidenced by the following:
Administrator confirmed R1 was a resident of the facility. Checks and physician’s report help to confirm R1 was a resident. R1 moved out after a week of living at the facility. R1’s responsible party was not given a copy of the admission agreement which would indicate refunds.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (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)
Page: 3 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
02/19/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200219133957

FACILITY NAME:HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTHFACILITY NUMBER:
198602418
ADMINISTRATOR:OGBECHIE, BIOSEH OFACILITY TYPE:
740
ADDRESS:120 S MYRTLE AVETELEPHONE:
(213) 478-0739
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 35DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Administrator, Lupe HarveyTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to administer correct medicine to residents.
Facility did not provide a clean and sanitary environment.
Staff did not ensure resident is provided an adequate amount of water.
Staff did not meet residents care needs resulting in hospitalization.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 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. LPA obtained checks made out to the facility and Resident #1's (R1) physician's report.

The investigation revealed the following: Allegation: Facility failed to administer correct medicine to residents. Allegedly facility administered morphine medication to R1 and R1 is allergic to the medicine. R1 was a resident of the facility for 1 week in February 2019 and moved out to a different location. Facility was not able to locate R1’s file (facility was previously cited for not having records). Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (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)
Page: 4 of 5
Control Number 28-AS-20200219133957
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
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
Therefore, LPA did not have access to R1’s medication records. Allegedly the 2 staff members that knew about the incident no longer work at the facility and there is no contact information for the staff. Facility staff were interviewed, and they did not have any knowledge of the incident and none of them remembered R1. Residents interviewed indicated they have had no medication issues. Staff training was reviewed, and it appears staff assisting with medication have been trained properly. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Facility did not provide a clean and sanitary environment. It’s alleged dirty dishes were left in R1’s room for an extended period of time. R1 moved out in February 2019 and the condition of the room cannot be observed. Facility was toured and appeared to be clean. Staff interviewed included caregivers, med techs and housekeeping. Staff denied the allegation and did not remember R1. Residents interviewed did not corroborate the allegation. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff did not ensure resident is provided an adequate amount of water. Allegedly R1 was transferred from the facility to the hospital and R1 was dehydrated. The complaint alleges R1 had drinking water in the room, but staff didn’t assist R1 with drinking the water. Staff interviewed denied not assisting residents with water. Staff interviewed didn’t remember R1 and had no knowledge of the incident. Residents interviewed did not corroborate the allegation. Residents indicated staff ensure residents have adequate drinking water. R1 has since passed and therefore could not be interviewed. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff did not meet residents care needs resulting in hospitalization. Allegedly R1 was diagnosed with dementia and was on hospice and needed 24 hour care. Allegedly neglect from facility staff resulted in R1 being hospitalized for pneumonia and dehydration. R1’s file was not available for review. R1 was a resident in 2019 and has since passed. Staff interviewed did not remember R1 and did not have any knowledge of the hospitalization. Residents interviewed did not remember R1 and did not report any similar incidents. The complaint did not include any medical records that would prove R1 was diagnosed with pneumonia or dehydration and that facility staff were responsible. Based on the information obtained, the allegation is unsubstantiated.

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. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (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)
Page: 5 of 5