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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:05:21 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: 30DATE:
11/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPA met with Facility Manager / Lupe Harvey who assisted with the visit. LPA explained the purpose of this visit is to conduct a health and safety check for the residents in care.

During today's visit, LPA toured the physical plant (inside) and inspected the auditory chimes located on all exit doors. The auditory chimes were observed to be operational. At approximately 11:10am, LPA observed the two stairwell exits located on the second floor (main building) were missing evacuation chairs.
(Per HSC ยง1569.695, a facility shall have an evacuation chair at each stairwell, on or before July 1, 2019.)

LPA toured the physical plant (outside patio area and near the cottages) to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA toured a resident room located in the detached apartment in the back and also in the detached cottage. The resident rooms were furnished appropriately. Each resident room has their own restroom. LPA reviewed the file of Resident 1 (R1) who resides in room A2, located in the detached apartment. The latest physician report for R1 is dated from 2019. LPA requested the Facility Manager to have R1 re-evaluated by her physician in order to ensure facility is providing the care and supervision to meet her needs. R1 will be evaluated by her physician, no later than 12/10/21.

The following deficiency was observed to be in violation of Health & Safety Code Sections 1569.695 (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: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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: 11/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited

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Emergency Plans. A facility shall have both of the following in place: An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by: At approximately 11:10am, LPA observed the two stairwell exits located on the second floor (main building) were missing evacuation chairs.
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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receipt for the purchase of the evacuation chairs must be forwarded to the
CCL office by the POC due date of 12/7/21.

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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: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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