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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 10/07/2021
Date Signed: 10/07/2021 04:04:36 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
02:30 PM
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
Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPAs met with Facility Manager / Lupe Harvey who assisted with the visit. LPAs explained the purpose of this visit is to conduct a health and safety check for the residents in care.
  • At approximately 11:45AM, LPAs toured the facility and tested the auditory chimes located on the exit doors of the facility (both floors) and observed the auditory chimes were operable.
  • At approximately 12:05PM, LPA Katrdzhyan toured the kitchen and observed an ample supply of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days.
  • At approximately 12:15PM, LPA Katrdzhyan reviewed the list of medications being administered to Resident #1 (R1) and discovered that the medications listed below were missing from the facility and not being administered per physician's orders;

    • • Fluoxetine 20 MG Capsule • Neurontin 600 MG Tablet • Tramadol 50 MG Tablet • Macrobid 100 MG Capsule • Divalproex 125 MG Tablet • Depakote 250 MG Tablet • Nitrostat 0.4 MG Sublingual Tablet
    • Fluoxetine 40 MG Capsule
  • Also, MULTI Vitamins & Minerals is being administered to R1 every morning without a written order / prescription from a physician.

The medication errors listed above present an immediate health and safety concern for R1.
The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Facility Manager 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: 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)
Page: 1 of 2
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: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited

1
2
3
4
5
6
7
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 approximately 12:15PM, LPA Katrdzhyan reviewed the list of medications being administered to Resident #1 (R1) and
8
9
10
11
12
13
14
discovered that the medications listed below were missing from the facility and not being administered per physician's orders;
• Fluoxetine 20 MG Capsule • Neurontin 600 MG Tablet • Tramadol 50 MG Tablet • Macrobid 100 MG Capsule • Divalproex 125 MG Tablet • Depakote 250 MG Tablet • Nitrostat 0.4 MG Sublingual Tablet
• Fluoxetine 40 MG Capsule.
Also, Kirkland Mature MULTI Vitamins & Minerals is being administered to R1 every morning without a written order / prescription from a physician.
8
9
10
11
12
13
14
and submit proof of correction to CCL by the POC due date.

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: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2