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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 10/28/2021
Date Signed: 10/28/2021 12:58:46 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
10/21/2021 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211021154112
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:
10/28/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff / Roselia Cecilio
Facility Manager / Lupe Harvey		TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Roselia Cecilio and was later joined by the Facility Manager / Lupe Harvey who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Facility is in disrepair".

During today's visit, LPA toured the facility with the assistance of the Facility Manager and measured the hot water temperature in the common bathrooms and in random resident rooms.

The investigation revealed the following;
Allegation: Facility is in disrepair. The details of this allegation states that the hot water is not working in the bathrooms and the elevator is out of order.

Please see LIC 9099C for additional information.
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: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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 3
Control Number 28-AS-20211021154112
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: 10/28/2021
NARRATIVE
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In reference to the hot water temperature, at 9:43AM, the hot water temperature was tested in resident room #3 and measured at 102.3 degrees F. At 10:12AM, the hot water temperature was tested in resident room #18 and measured at 99.5 degrees F. Based on LPA's observations, there is sufficient evidence to support that the hot water temperature is not in compliance with Title 22 Regulation guidelines.

In reference to the elevator being out of order, at 11:30AM, LPA observed the elevator door was closed shut with a padlock. LPA was unable to press the elevator button because the elevator button was also closed shut with a padlock. According to the Facility Manager the elevator has been out of order for months. Based on LPA's observations, there is sufficient evidence to support that the elevator is in disrepair.

Based on LPA’s observations and interviews which were conducted, 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 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: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20211021154112
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: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2021
Section Cited
CCR
87303(e)(2)
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Maintenance and Operation. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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Facility staff adjusted the hot water temperature and LPA re-tested the hot water temperature in resident rooms #3 and #18 and it was measured within Title 22 Regulation guidelines.

***Citation was cleared at the time of visit and no further action is needed***
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This requirement is not met as evidenced by;
On 10/28/21, at 9:43AM, the hot water temperature was tested in resident room #3 and measured at 102.3 degrees F. At 10:12AM, the hot water temperature was tested in resident room #18 and measured at 99.5 degrees F. This poses an immediate health, safety risk to persons in care.
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Type B
11/29/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Licensee will ensure the elevator is in good repair/operable and submit proof of invoice showing the repairs made. The POC must be submitted to CCL by the due date of 11/29/21.
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On 10/28/21, at 11:30AM, LPA observed the elevator door was closed shut with a padlock. LPA was unable to press the elevator button because the elevator button was also closed shut with a padlock. According to the Facility Manager the elevator has been out of order for months.
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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: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3