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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 04:06:18 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: 31DATE:
10/07/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted a collateral visit to the facility. Upon arriving at the facility, LPAs met with Facility Manager / Lupe Harvey who assisted with the visit. LPAs explained the purpose for today's Collateral Case Management visit is to disclose the overdue annual fees for Serenity Care Health Evergreen Cottage #198602286.

The amount overdue is $1,484.00, with a due date of March 14, 2021.

Facility Manager / Lupe Harvey at Henrietta's Leven Oaks by Serenity Care was asked to provide a copy of this report to Corporate so that payment maybe issued to DSS / CCL for the overdue fees.

An exit interview was conducted and a copy of this report was 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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