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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 03/02/2022
Date Signed: 03/02/2022 11:08:23 AM


Document Has Been Signed on 03/02/2022 11:08 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:
03/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
11:15 AM
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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(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 the visit conducted on 2/16/22, 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 the visit conducted on 2/16/22, 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 is 2/21/22.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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: 03/02/2022
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The Licensee submitted the POC on 2/24/22 (three days late), therefore a Civil Penalty is being issued for period 2/21/22 - 2/23/22. 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 2/24/22.


A deficiency is cited per California code of Regulations, Title 22, Division 6
LPA explained the citation, 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: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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