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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 02/16/2022
Date Signed: 02/16/2022 01:02:48 PM


Document Has Been Signed on 02/16/2022 01:02 PM - It Cannot Be Edited

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: 32DATE:
02/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
01:15 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 citations issued during the 2/2/22 Required – 1 Year Inspection. Upon arriving at the facility, LPA met with Facility Manager / Lupe Harvey who assisted with the visit. The purpose of this visit was explained.

On 2/2/22 the facility was cited for:



87303(e)(2) - 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 degrees F (49 degree C).
This requirement is not met as evidenced by: On 2/2/22, between the hours of 11am and 12:15pm, LPA measured the hot water temperature in the rooms listed below and the hot water temperature was not measured in compliance with Title 22 Regulations. Room A3 was measured at 122.1 degrees F. Room B1 was measured at 90.2 degrees F. Room 35 was measured at 104 degrees F. This poses an immediate health, safety risk to persons in care.
The Plan of Correction (POC) for this deficiency stated that the Licensee will ensure that the hot water temperature is maintained between 105 degrees F - 120 degrees F throughout the facility as required and submit a log for the next 24 hours showing the actual reading in rooms A3, B1 and 35.
POC must be submitted to CCL by the POC due date of 2/3/22.
The Licensee submitted the POC on 2/4/22 (one day late), therefore a Civil Penalty is being issued for period 2/3/22 - 2/3/22. Total of 1 day, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $100.00. Deficiency is cleared as of 2/4/22.

(Please see LIC 809C for additional information)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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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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
VISIT DATE: 02/16/2022
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87465(a)(5) - Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by: On 2/2/22, at 1pm, LPA observed the facility was missing a physician's order for the Fish Oil Gummies and B12 being administered to R2. This poses an immediate health, safety risk to persons in care.
The Plan of Correction (POC) for this deficiency stated that the Administrator will obtain a physician's order for the Fish Oil Gummies and B12 for R2 and submit proof of correction to CCL by the POC due date of 2/3/22.
The Administrator submitted the POC on 2/6/22 (three days late), therefore Civil Penalties are being issued for period 2/3/22 - 2/5/22. Total of 3 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $300.00. Deficiency is cleared as of 2/6/22.

87303(a) - 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: On 2/2/22, between the hours of 11am and 1pm, the following items were observed to be in disrepair at the facility. The aerator located on the faucet in room A2 was spraying water from the side of the faucet and needed to be replaced. The closet door in room 32 was missing a handle. The water would not drain in sink located in room 35. The ceiling in room 14 was damaged from the rain and needed to be repaired.
The Plan of Correction (POC) for this deficiency stated that the Licensee will repair the items listed under this deficiency and submit proof of correction to CCL by the POC due date of 2/16/22.
During today's visit, LPA took a walk through of the facility and observed the aerator located on the faucet in room A2 was replaced and working properly. A handle was placed on the closet door in room 32 and was working properly. The sink in room 35 was repaired and water was draining without issues.
During today's visit, the Facility Manager submitted a request for an extension regarding the ceiling in room 14 as it had not been repaired due to maintenance not being able to complete the work. LPA granted the extension and the new POC due date to have the ceiling repaired will be 2/21/22.

Deficiencies are cited per California code of Regulations, Title 22, Division 6
LPA explained the citations, civil penalty assessment, and appeal rights.
Exit interview was conducted and 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: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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