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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 09/23/2021
Date Signed: 09/28/2021 11:13:47 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: 31DATE:
09/23/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction citation issued during the case management visit conducted on 7/16/2021. The purpose of this visit was explained to Facility Manager / Lupe Harvey.

On 7/16/2021 the facility was cited for:

HSC ยง1569.605 - Licensee failed to submit plan of correction proof of liability insurance to CCL on POC due date July 19, 2021 5:00 pm. As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties were issued for period 9/10/21 - 9/23/21. Total of 14 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 1,400.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.



A deficiencies is cited per Health & Safety Code Sections 1569.605 and Title 22.

LPA explained the citation, civil penalty assessment, and appeal rights.

Exit interview was conducted with Facility Manager / Lupe Harvey. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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