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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 02/02/2022
Date Signed: 02/16/2022 11:15:58 AM


Document Has Been Signed on 02/16/2022 11:15 AM - 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: 31DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year Inspection. Upon arriving at the facility, LPA met with Facility Manager / Lupe Harvey who assisted with the visit. The facility is licensed to serve for a capacity of 80 residents (80 Non-Ambulatory, of which 5 may be bedridden) ages 60 and above. Rooms #4, 5, 8, 9 and 12 are designated for bedridden residents. The facility has an approved Hospice Waiver on file for fifteen (15) Residents. The facility also has an approved Dementia Care plan as part of their operation.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Facility is located in Old Town Monrovia. The main building consists of two floors, there is a detached apartment in the back with 2 rooms located on the first floor and 3 rooms located on the second floor along with two detached cottages. The first floor in the main building consists of a kitchen, dining room, living room/television room, reception/office area, conference room, laundry room and resident rooms. The second floor of the main building consists of resident rooms.

LPA toured a random selection of resident rooms on each floor. Resident rooms were furnished appropriately. The bathrooms were observed to be clean and operational w/grab bars. The resident rooms have signal systems located in each room. The signal system was tested in various locations and observed to be operable. The hot water temperature was tested throughout the facility. The facility has central air and heating accommodations.

The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas. Fire extinguishers were observed throughout the facility and were fully charged and in compliance. The carbon monoxide detectors were tested and operable. The front grounds of the
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
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: 02/02/2022
NARRATIVE
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facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the back yard. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises.

Medications are centrally stored in the locked medication room in the dining room area. A random selection of medications were reviewed to ensure they are being administered as prescribed.

The following deficiencies were observed during today's visit;
  • 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.
  • At 12pm, "Xtra" laundry detergent was observed in the laundry room accessible to residents.
  • At 12:01pm, the exit door located near the kitchen area was missing an auditory chime.
  • At 12:22pm, LPA observed the smoke detector in room 14 was missing.
  • At 12:30pm, LPA observed rubbing alcohol underneath the sink in room 22.
  • At 12:34pm, LPA observed Pepto Bismol, Vitamin B12 and B Complex in room 17 belonging to
Resident 1 (R1). Per physician's Report, R1 is not able to store or administer own medications.
  • At 1pm, LPA observed the facility was missing a physician's order for the Fish Oil Gummies and B12 being administered to Resident 2 (R2).
  • 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 following deficiencies were observed to be in violation under California Code of Regulations Title 22.
(refer to 809D).

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: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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Document Has Been Signed on 02/16/2022 11:15 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2022
Section Cited

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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 degrees F (49 degree C).
This requirement is not met as evidenced by:
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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.
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Type A
02/02/2022
Section Cited

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Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement is not met as evidenced by:
At 12pm, "Xtra" laundry detergent was observed in the laundry room accessible to residents.
At 12:30pm, LPA observed rubbing alcohol underneath the sink in room 22. This poses an immediate health, safety risk to persons in care.
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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: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 02/16/2022 11:15 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2022
Section Cited

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Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.


This requirement is not met as evidenced by:
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At 12:01pm, the exit door located near the kitchen area was missing an auditory chime.
This poses an immediate health, safety risk to persons in care.
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Type A
02/03/2022
Section Cited

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement is not met as evidenced by:
At 12:22pm, LPA observed the smoke detector in room 14 was missing. This poses an immediate health, safety risk to persons in care.
Type A
02/03/2022
Section Cited

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Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by: 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.
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: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/16/2022 11:16 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2022
Section Cited

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Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement is not met as evidenced by:
At 12:34pm, LPA observed Pepto Bismol, Vitamin B12 and B Complex in room 17 belonging to Resident 1 (R1). Per physician's Report, R1 is not able to store or administer own medications. This poses an immediate health, safety risk to persons in care.
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Type B
02/16/2022
Section Cited

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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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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.
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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: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5