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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 05/12/2021
Date Signed: 05/12/2021 04:11:22 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2019 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191017164515
FACILITY NAME:HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTHFACILITY NUMBER:
198602418
ADMINISTRATOR:OGBECHIE, BIOSEH OFACILITY TYPE:
740
ADDRESS:120 S MYRTLE AVETELEPHONE:
(213) 478-0739
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 33DATE:
05/12/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator / Lupe HarveyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident has sustained multiple falls at the facility.

Facility has insufficient staff.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nina Galarza conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegations of "Resident has sustained multiple falls at the facility" and "Facility has insufficient staff". Upon arriving at the facility, LPAs met with Administrator / Lupe Harvey who assisted with the visit.
LPA Katrdzhyan conducted the initial complaint visit to this facility on 10/23/2019. During the course of the investigation, LPA conducted interviews of various persons to include the Facility Manager, Staff members #1 through 5 (S1 - S5) and Residents 2 through 4 (R2 - R4). LPA was unable to interview R1 as R1 expired on 11/9/2019. LPA also reviewed the file of R1 and obtained copies of the following documents;

• Unusual Incident/Injury Report • Identification and Emergency Information • Preplacement Appraisal Information • Resident Appraisal • History of Physical • Daily Caregiver Notes Form for period: 10/10/19 - 10/23/19 • Shower Schedule • Admission Agreement • Advanced Directive • Durable Power of Attorney for Health Care • RCFE Levels of Care Assessment Tool.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 28-AS-20191017164515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/12/2021
NARRATIVE
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The investigation revealed the following;

Allegation: Resident has sustained multiple falls at the facility. The details of this allegation stated R1 had a fall at the facility on 9/14/19 and suffered a break to her left hip and a cut to the back of her head. After returning from the hospital, R1 sustained another fall.
According to the Unusual Incident/Injury Reports submitted to CCL, it is noted that on 9/14/19, R1 sustained a fall at the facility on the morning of 9/14/19 and was transported to the hospital for an evaluation. While at the hospital, it was discovered that R1 suffered a break to her left hip and a cut to the back of her head. On 10/17/19, R1 sustained another fall at the facility. The Resident Appraisal and Preplacement Appraisal Information for R1 states R1 is a fall risk and has issues with her balance. Based on interviews conducted, the statements obtained were consistent in reference to R1 being a fall risk and having a history of falls. According the RCFE Levels of Care Assessment Tool completed by the Henrietta's Leven Oaks By Serenity Care Health on 8/6/19, it is noted that R1 has an unsteady gait, needs assistance with transfers, bathing, dressing, eating, toileting, brushing teeth and taking medications. After reviewing the file of R1, LPA did not observe a fall risk plan. Statements obtained corroborated that the facility did not have a fall risk plan for R1, in order to monitor R1 and prevent future falls from occurring. Based on LPA’s interviews which were conducted and record reviews, there is sufficient evidence to support the allegation of "Resident has sustained multiple falls at the facility".

Allegation: "Facility has insufficient staff". The details of this allegation stated that the response time for staff responding to resident needs is between 20 - 50 minutes due to insufficient staffing.
Based on interviews conducted, LPA learned that the facility had insufficient staffing prior to the incident involving R1, which occurred on 9/14/19. It was revealed that there were 4 caregivers working at the facility from 6AM to 6PM (Monday - Friday), of which one caregiver was inside the dining room, leaving only three caregivers on the floor. When one of the caregivers went to break or lunch there were two caregivers left to assist the residents, one caregiver on each floor. The caregivers on each floor were responsible for changing, feeding, showering the residents, doing tray service and assisting with the call button. After the incident involving R1, facility hired additional staff to help better meet the needs of all residents. Based on LPA’s interviews which were conducted, there is sufficient evidence to support the allegation of "Facility has insufficient staff".

(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: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20191017164515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/12/2021
NARRATIVE
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Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Administrator 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: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20191017164515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
On 9/14/19, R1 sustained a fall at the facility resulting a break to her left hip and a cut to
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Administrator will develop a plan for residents who are at risk of falls ensuring how staff will monitor residents in order to prevent future falls. The plan will include the number of staff members covering each shift to adequately supervise the residents. A new staff schedule (LIC 500) will be submitted along with the plan.
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the back of her head. On 10/17/19, R1 sustained another fall at the facility. The Resident Appraisal and Preplacement Appraisal Information for R1 states R1 is a fall risk and has issues with her balance. Based on interviews conducted, the statements obtained were consistent in reference to R1 being a fall risk and having a history of falls. After reviewing the file of R1, LPA did not observe a fall risk plan. Statements obtained corroborated that the facility did not have a fall risk plan for R1.
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Plan must be submitted to CCL by the POC due date 5/13/21.
Type A
05/13/2021
Section Cited
CCR
87411
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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
This requirement is not met as evidenced by:
Based on interviews conducted, LPA learned that the facility had insufficient staffing prior to the incident involving R1, which occurred on
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Administrator will develop a plan ensuring facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Plan must be submitted to CCL by the POC due date 5/13/21.
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9/14/19. It was revealed that there were 4 caregivers working at the facility from 6AM to 6PM (Monday - Friday), of which one caregiver was inside the dining room, leaving only three caregivers on the floor. When one of the caregivers went to break or lunch there were two caregivers left to assist the residents, one caregiver on each floor. The caregivers on each floor were responsible for changing, feeding, showering the residents, doing tray service and assisting with the call button.
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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: 05/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2019 and conducted by Evaluator Joe Katrdzhyan
COMPLAINT CONTROL NUMBER: 28-AS-20191017164515

FACILITY NAME:HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTHFACILITY NUMBER:
198602418
ADMINISTRATOR:OGBECHIE, BIOSEH OFACILITY TYPE:
740
ADDRESS:120 S MYRTLE AVETELEPHONE:
(213) 478-0739
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 33DATE:
05/12/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator / Lupe HarveyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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5
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Facility is not assisting resident with bathing as required.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nina Galarza conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Facility is not assisting resident with bathing as required". Upon arriving at the facility, LPAs met with Administrator / Lupe Harvey who assisted with the visit.
LPA Katrdzhyan conducted the initial complaint visit to this facility on 10/23/2019. During the course of the investigation, LPA conducted interviews of various persons to include the Facility Manager, Staff members #1 through 5 (S1 - S5) and Residents 2 through 4 (R2 - R4). LPA was unable to interview R1 as R1 expired on 11/9/2019. LPA also reviewed the file of R1 and obtained copies of the following documents;

• Unusual Incident/Injury Report • Identification and Emergency Information • Preplacement Appraisal Information • Resident Appraisal • History of Physical • Daily Caregiver Notes Form for period: 10/10/19 - 10/23/19 • Shower Schedule • Admission Agreement • Advanced Directive • Durable Power of Attorney for Health Care • RCFE Levels of Care Assessment Tool.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20191017164515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/12/2021
NARRATIVE
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The investigation revealed the following;

During the course of this investigation, LPA obtained a copy of the resident shower schedule and verified with residents and staff that the residents are getting their showers regularly on their scheduled days. LPA learned that in the event a resident refuses to shower on their scheduled date, arrangements are made to schedule the shower on a later time or date. Based on interviews and record reviews, the statements obtained were inconsistent with this allegation. There is insufficient evidence to support the allegation of "Facility is not assisting resident with bathing as required"

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is found to be Unsubstantiated.

An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6