198602418-5-24-2021-28-AS-MVAO-C4AMY4-20210624100057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 05/24/2021
Date Signed: 05/24/2021 01:30:55 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
12/31/2019 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191231115703

FACILITY NAME:	HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTH		FACILITY NUMBER:	198602418
ADMINISTRATOR:	OGBECHIE, BIOSEH O		FACILITY TYPE:	740
ADDRESS:	120 S MYRTLE AVE		TELEPHONE:	(213) 478-0739
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	80	CENSUS: 33	DATE:	05/24/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Facility Manager / Lupe Harvey		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff lack qualifications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Facility staff lack qualifications". Upon arriving at the facility, LPA met with Facility Manager / Lupe Harvey who assisted with the visit.

LPA Katrdzhyan conducted prior visits to this facility on 1/8/20 and 1/23/20. During the course of the investigation, LPA conducted interviews of various persons to include Staff #1 (S1), former Facility Manager / Dania Thomas and current Facility Manager / Lupe Harvey. LPA also reviewed the facility files of former Facility Manager and S1.

The investigation revealed the following;
Allegation: Facility staff lack qualifications. The details of this allegation states, S1 and former Facility Manager / Dania Thomas are administering medications to residents prior to having certification and training on medication management. (please see LIC 9099C for additional information)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20191231115703

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: 05/24/2021

NARRATIVE

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Based on interviews conducted, LPA discovered that S1 and former Facility Manager / Dania Thomas were
both administering medications to residents. On 5/24/21, at 11AM, LPA reviewed facility files for former Facility Manager and S1 and did not observe certification of training on medication administration. As a result, there were many medication errors noted during the visit conducted on 1/23/20, by LPA Katrdzhyan. Deficiencies were issued at the time of visit.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is 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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20191231115703

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: 05/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/01/2021 Section Cited CCR 1569.69(b)	1 2 3 4 5 6 7	§1569.69 Employees assisting residents with self-administration of medication; training requirements. Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.	1 2 3 4 5 6 7	The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with Health and Safety Code, Section 1569.69. Written POC must be submitted to CCL by the POC due date.
	8 9 10 11 12 13 14	This requirement was not met by evidence of: Based on interviews conducted, LPA discovered that S1 and former Facility Manager / Dania Thomas were both administering medications to residents. On 5/24/21, at 11AM, LPA reviewed facility files for former Facility Manager and S1 and did not observe certification of training on medication administration. As a result, there were many medication errors noted during the visit conducted on 1/23/20, by LPA Katrdzhyan.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC9099 (FAS) - (06/04)

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