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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 11/17/2021
Date Signed: 11/17/2021 10:24:20 AM

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:
11/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Staff / Roselia Aquino
Facility Manager / Lupe Harvey		TIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced case management visit to this facility to follow up on the concern regarding Licensee failing to submit liability of insurance for this facility. Upon arriving at the facility, LPAs met with Staff / Roselia Aquino and were later joined by the Facility Manager / Lupe Harvey who assisted with the visit. The purpose of this visit was explained to the Facility Manager.

Per HSC ยง1569.605 Liability insurance; coverage requirements - On and after July 1, 2015, 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. Licensee has failed to submit proof of liability insurance to CCL.

Deficiencies are cited per Health & Safety Code Section 1569.605.


LPA spoke to Facility Manager / Lupe Harvey and explained citation and appeal rights.
Exit interview was conducted with 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: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited

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Liability insurance; coverage requirements.
On and after July 1, 2015, 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
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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.

Based on observation and interviews conducted, Licensee failed to provide proof of liability insurance during this visit.
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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: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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