198602418-6-30-2021-28-AS-FFIS-C56UUT-20210722155401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 06/30/2021
Date Signed: 06/30/2021 03:32:21 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
02/13/2020 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200213111123

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: 31	DATE:	06/30/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lupe Harvey - Facility Manager		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff do not have required training

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent visit to the facility in regards to the above mentioned allegation. Upon arriving at the facility, LPA met with Facility Manager / Lupe Harvey who assisted with the visit.

LPA Villalobos conducted prior visit to this facility on 2/20/20. During the course of the investigation, LPA toured the facility and conducted interviews with Staff #2-#4 (S2-S4), and Resident #1 (R1). LPA unable to interview S1 as S1 no longer works in the facility. LPA also contacted R1's hospice agency.

On Todays visit, LPA interviewed Staff #5-#6 (S5 and S6) and Residents #2-#3 (R2 and R3). Reviewed Staff files and R1's file. LPA obtained copy of LIC 500 and current resident roster. LPA also toured the facility.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

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-20200213111123

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: 06/30/2021

NARRATIVE

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In regards to the allegation : "staff do not have required training" it was alleged that S1 was cleaning R1's g-tube when it popped out and started bleeding. (6) of (6) staff interviewed denied and could not corroborate the allegation. (3) of (3) residents interviewed could not corroborate the allegation. There was no specific date provided to LPA on when the incident occurred and who would have witnessed it. Interview with Licensed Nurse from R1's hospice agency on 2/20/20 shows that the hospice agency would come to the facility 3 times a week to provide care and required services to R1. The hospice agency was in plans to train facility staff on R1's needs. LPA reviewed staff files and as of the time of this visit, the staff of the facility have training on NG-Tube care and feeding. S1's file does not have the before mentioned training but it is unknown whether alleged incident occurred. S1 would only need the training if in fact S1 was cleaning R1's g-tube. Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all the allegations are UNSUBSTANTIATED.

No deficiencies were cited during this visit. Exit Interview was conducted with Lupe Harvey and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

LIC9099 (FAS) - (06/04)

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