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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 10/07/2021
Date Signed: 10/07/2021 04:03:21 PM

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: DATE:
10/07/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Staff / Victoria "Vicky" Vazquez
Facility Manager / Lupe Harvey		TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction citations issued during the 7/16/2021 case management visit. Upon arriving at the facility, LPAs met with Staff / Victoria "Vicky" Vazquez and were later joined by the Facility Manager / Lupe Harvey who assisted with the visit. The purpose of this visit was explained to the Facility Manager.

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 18, 2021. As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties are being issued for period 9/24/21- 10/7/21. 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.

During today's visit, the Facility Manager provided a copy of the Certificate of Liability Insurance, pending review.



Deficiencies are cited per Health & Safety Code Sections 1569.605.
LPA explained the citations, 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: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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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