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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 10/08/2021
Date Signed: 10/08/2021 02:33:16 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: 15DATE:
10/08/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator, Lupe HarveyTIME COMPLETED:
02:42 PM
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Licensing Program Analyst (LPA) Vasallo and Margaryan conducted a Plan of Correction (POC) visit. On 9/2/21, LPA Vasallo issued deficiencies regarding a refund for Resident #1's (R1) responsible party. The original POC was due on 9/10/21. The facility requested a POC extension and the extension was granted for 10/1/21. As of today (10/8/21) the facility has not submitted the POC for the deficiencies cited. Therefore, civil penalties will be issued for late POC.

Exit interview held with administrator. A copy of the report, appeal rights and civil penalty form were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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