<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 02/26/2022
Date Signed: 02/26/2022 01:57:46 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
02/24/2020 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20200224152952
FACILITY NAME:HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTHFACILITY NUMBER:
198602418
ADMINISTRATOR:OGBECHIE, BIOSEH OFACILITY TYPE:
740
ADDRESS:120 S MYRTLE AVETELEPHONE:
(213) 478-0739
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 31DATE:
02/26/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Med Tech Madelene SanchezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulting in resident eloping from facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced subsequent complaint visit to the facility. LPA met the Med Tech Madelene Sanchez and informed that this visit was conducted to deliver final outcome of investigation.
The investigation consisted of the following: On 2/27/20, LPA Katrdzhyan interviewed 5 staff. On 10/07/21, LPAs interviewed 5 staff and 5 residents. On 11/17/21 LPA Margaryan interviewed 5 residents, 4 staff and obtained copies of documents related to the allegation.

--Lack of supervision resulting in resident eloping from facility.
It was reported that on two occasions, the resident #1 (R1) was able to leave the facility and the staff were not aware that the resident was gone. To investigate the allegation on 02/27/2020 LPA Katrdzhyan interviewed staff and gathered R1’s facility records. On 10/07/2021 and 11/17/2021 LPA Margaryan spoke with the Administrator, residents and facility staff.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2022
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 5
Control Number 28-AS-20200224152952
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: 02/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The Administrator and staff admitted that R1 left the facility unassisted in more than one occasions.
A review of facility records revealed that due to diagnoses of dementia, R1 was requiring close supervision and was unable to leave facility unassisted.
The information revealed from the interviews and record review verifies the allegation. Therefore, the allegation is SUBSTANTIATED at this time

Under 22 Regulation The following citation was issued and recorded on LIC 9099D
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20200224152952
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: 02/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2022
Section Cited
CCR
87464(d)
1
2
3
4
5
6
7
 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept ... a resident for care, the facility shall be responsible for meeting the resident's needs. … and providing the other basic services… either directly or through outside resources. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee will provide written statement explaining how the facility will ensure that residents with dementia are supervised as required.
8
9
10
11
12
13
14
Based on interviews and record review the Licensee did not comply for the Section noted above. R1 who is unable to leave the facility unattended, eloped from the facility more than once. This possess an immediate health and safety risk to residents’ in care.
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 HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/24/2020 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20200224152952

FACILITY NAME:HENRIETTA'S LEVEN OAKS BY SERENITY CARE HEALTHFACILITY NUMBER:
198602418
ADMINISTRATOR:OGBECHIE, BIOSEH OFACILITY TYPE:
740
ADDRESS:120 S MYRTLE AVETELEPHONE:
(213) 478-0739
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 31DATE:
02/26/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Med Tech Madelene SanchezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulting in resident being hit by another resident in care.
Resident was bit by another resident in care.
Facility is in disrepair.
Resident was left in soiled undergarments for a long period of time.
Staff did not do resident's laundry.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
--Lack of supervision resulting in resident being hit by another resident in care.
--Resident was bit by another resident in care.
It was reported that while in care the resident #1 (R1) was slapped and bitted by another resident twice.
To investigate this allegation on 10/07/2021 and 11/17/2021 LPA Margaryan spoke with the Administrator and other staff. Staff denied seeing R1 being slapped or bitten by another resident(s). LPA spoke with more than 10% of facility residents and they indicated that they never witnessed R1 being slapped or bitten by another resident(s). At the time of investigation R1 was no longer in the facility.
The information gathered during this investigation, does not support the above noted allegations. Therefore, both allegations are UNSUBSTANTIATED at this time.

--Facility is in disrepair.
It was reported that the water line on one of the toilets at the facility is not working.
To investigate this allegation on 10/07/2021 LPA Margaryan inspected the facility including R1’s and other residents’ bedrooms. LPA observed no disrepair in the bathrooms and the water lines were working.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20200224152952
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: 02/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In addition. On 10/07/21 and 11/17/21 LPA spoke with the staff and more than 10% of residents.
No staff or residents had any complains or concerns about the toilets being clogged or not having a water in the bathrooms.
Based on inspection, observation and interviews there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--Resident was left in soiled undergarments for a long period of time.
It was reported that staff are constantly leaving residents’ in soiled depends.
To investigate this allegation on 10/07/2021 LPA spoke with five (5) staff. Staff stated that they check incontinent residents every two to three hours and change their diapers and briefs as needed.
On 11/17/2021 LPA Margaryan spoke with the five (5) incontinent residents. The residents did not address any concerns regarding their incontinent care.
At the time of this visit, LPA Margaryan requested and reviewed facility incontinent care log. Information revealed from document review supported the information received from staff.
Based on interviews, and record review there is no relevant information to verify the allegation. Hence, the allegation is UNSUBSTANTIATED at this time.

-- Staff did not do resident's laundry.
Concerns were addressed that R1’s laundry hamper had soiled clothing inside of it.
To investigate this allegation on 10/07/2021 and 11/17/2021 LPA Margaryan spoke with the staff and residents. Interviews revealed that each resident has a hamper in their room for dirty clothes. The residents’ laundry being picked up and washed once a week.
No resident expressed any concerns regarding the laundry service provided by facility staff.
The information revealed during this investigation did not support the allegation. Therefore, the allegation deemed UNSUBSTANTIATED at this time.

No citations were issued at the time of this visit.
Exit interview was conducted and copy of report provided.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5