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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 10/20/2021
Date Signed: 10/20/2021 12:06:22 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: 29DATE:
10/20/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
12:15 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 citations issued during the 7/16/2021 case management visit. Upon arriving at the facility, LPA met with 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 §1569.605 - Licensee failed to submit plan of correction proof of liability insurance to CCL on POC due date July 18, 2021. During the POC visit conducted on 10/7/21, the Facility Manager provided a copy of the Certificate of Liability Insurance (CLI). After returning to the Licensing Office, LPA Katrdzhyan reviewed the coverages listed on the CLI and contacted the representative at the insurance carrier and verified that Serenity Care Health Corporation covers a total of four (4) facilities (listed below), and therefore all four (4) facilities share the "General Aggregate" coverage of $3,000,000. Per HSC §1569.605, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. Since Serenity Care Health Corporation covers a total of four (4) facilities, the "General Aggregate" coverage needs to reflect $12,000,000. As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties are being issued for period 10/8/21 - 10/20/21. Total of 13 days, at $ 100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $1,300.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.

  • Henrietta's Leven Oaks By Serenity Care Health #198602418
  • Bentley Hills By Serenity Care Health #197608988

(please see LIC 9099C for additional information)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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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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
VISIT DATE: 10/20/2021
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  • Bentley Suites By Serenity Care Health #197609123
  • Hannah's Home By Serenity Care Health


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: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
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