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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 09/28/2021
Date Signed: 09/28/2021 11:33:17 AM

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: 32DATE:
09/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Luis Mora conducted an unannounced case management visit to this facility to ensure the Accusation/CDSS No. 6120010302E was posted as required by Law. In addition, to correct licensing reports originally issued on 7/16/2021, 7/29/2021, 8/12/2021, 8/23/2021, 8/31/2021. Upon arriving at the facility, LPAs met with Facility Manager / Lupe Harvey who assisted with the visit. LPAs explained the reason for today's visit.

The Accusation was served to the Licensee "Serenity Care Health Corporation" via certified mail on June 16, 2021. The Accusation was not observed to be posted in a conspicuous location on 07/16/2021. The Licensee did not provide written notification to the residents, their responsible parties, or the long-term care ombudsman, as required. A copy of the Accusation was provided to staff. Staff were instructed to immediately post the Accusation.

Civil penalties will be assessed against any facility that fails to take corrective action within the described time periods. Per the California Health & Safety Code Section 1569.38, you are hereby notified that a $100 civil penalty will be assessed for 7/16/21, Health & Safety Code Section 1569.38 requirements were not met. The total civil penalty for each day shall not exceed $100/day regardless of the number of notices the licensee fails to send that day. The total civil penalty for a continuous violation shall not exceed $5,000.

Civil penalties will accrue until Community Care Licensing has received proof that all required parties have received written notification of the revocation action.

The following concerns were also observed during the initial visit on 7/16/21;

(please see LIC 9099C for additional information)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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 5
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
VISIT DATE: 09/28/2021
NARRATIVE
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· At 8:30AM, upon walking inside the facility through the main entrance, LPAs observed the auditory chime located on the front door was turned off making it inoperable. During the visit conducted on 7/16/21, staff turned the auditory chime on, making it operable. Deficiency was cleared on 7/16/21.

· During today's visit, LPAs discovered that Staff / Raymond Malgapo has been employed and working at this facility prior to obtaining a California clearance or a criminal record exemption as required by the Department. During the visit conducted on 7/16/21, Facility Manager / Lupe Harvey sent Staff / Raymond Malgapo home and stated that Mr. Malgapo will not return to work until he has obtained a California clearance or a criminal record exemption as required by the Department. Deficiency was cleared on 8/23/21.

· At 10:34AM, LPAs reviewed medications and discovered Potassium Chloride 8mEq ER Tab (one tab by mouth daily with food) and Vitamins & Minerals HP Tab (one tab by mouth daily) were not being administered to R1 as prescribed by the physician. The Potassium Chloride 8mEq ER Tab and Vitamins & Minerals HP Tab were missing. The plan of correction was due on 7/17/21 and Licensee submitted proof showing the facility obtained the missing medications, Potassium Chloride 8mEq ER Tab and Vitamins & Minerals HP Tab for R1 on 7/19/21. Deficiency was cleared on 7/19/21.


The following deficiencies were cited.

An exit interview was conducted with Lupe Harvey. A copy of this report was provided 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: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2021
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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On 7/16/21, at 8:30AM, upon walking inside the facility through the main entrance, LPAs observed the auditory chime located on the front door was turned off making it inoperable.
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Type B
09/28/2021
Section Cited

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Posting of Licensing reports, disclosure to new residents: Posting of Licensing reports, disclosure to new residents: A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events; The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50.
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This requirement was not met, as evidenced by: Based on LPAs observations during initial visit 7/16/21, there was no supporting evidence provided to indicate that licensee notified residents/ responsible parties of the Accusation as required.
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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: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2021
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department.
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This requirement is not being met as evidenced by:
During the visit conducted on 7/16/21, LPAs discovered that Staff / Raymond Malgapo has been employed and working at this facility prior to obtaining a California clearance or a criminal record exemption as required by the Department.
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A civil penalty in the amount of $500.00 was issued.
Type A
09/28/2021
Section Cited

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Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by;
At 10:34AM, LPAs reviewed medications and discovered Potassium Chloride 8mEq ER Tab (one tab by mouth daily with food) and Vitamins
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& Minerals HP Tab (one tab by mouth daily) were not being administered to R1 as prescribed by the physician. The Potassium Chloride 8mEq ER Tab and Vitamins & Minerals HP Tab were missing.
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A civil penalty in the amount of $200 was issued for period 7/18/21 - 7/19/21.
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: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2021
Section Cited

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Posting of Licensing reports, disclosure to new residents: Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, that may include where the mail boxes are located, where the facility license is posted, or any other easily accessible location in the facility.
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This requirement was not met, as evidenced by: Based on LPAs observations during the initial visit conducted on 7/16/21 the Accusation was not posted in a conspicuous location as required.
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Type B
09/29/2021
Section Cited

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Liability insurance; coverage requirement; On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
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This requirement was not met, as evidenced by: Based on observations during initial visit 7/16/21 (initial date of visit), the licensee did not submit proof or verification of Liability Insurance.
During today’s visit LPA has not obtained verification of Liability Insurance.
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from 7/18/21 - 7/29/21, in the amount of 1,200.
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: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5