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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 01/19/2022
Date Signed: 01/19/2022 09:53:55 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: 31DATE:
01/19/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: Facility Manager / Lupe Harvey TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Plan of Correction (POC) visit to follow up on the Plan of Correction citation issued during the 11/17/2021 case management visit. Upon arriving at the facility, LPA met with Facility LPAs met with Staff / Claudie Sanchez 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.

On 11/17/21 the facility was cited for:

HSC §1569.605 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.

On 11/29/21, the Facility Manager provided a copy of the Certificate of Liability Insurance (CLI) to CCL (via email), and after further review by CCL, it was determined that the policy did not meet the requirements per HSC §1569.605. Civil Penalties are being issued for period (01/07/22 -01/19/22). Total of 13 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $1,300.00.

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) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
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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