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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 12/14/2021
Date Signed: 12/14/2021 11:48:17 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: 30DATE:
12/14/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
12:00 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 citation issued during the 11/30/2021 case management visit. Upon arriving at the facility, LPA met with Staff / Roselia Aquino Cecilio and was later joined by the Facility Manager / Lupe Harvey who assisted with the visit. The purpose of this visit was explained to the Facility Manager.

On 11/30/2021 the facility was cited for:

HSC ยง1569.695(f)(1) 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: On 11/30/21, at approximately 11:10am, LPA observed the two stairwell exits located on the second floor (main building) were missing evacuation chairs. 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. The Plan Of Correction (POC) was due to CCL on 12/7/21.



On 12/9/21, the Facility Manager provided a copy of the invoice (via email), showing the purchase of two (2) evacuation chairs. Facility failed to submit the POC to CCL by the POC due date of 12/7/21, therefore civil penalties are being issued for period 12/8/21 - 12/9/21. Total of 2 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $200.00.

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: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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