198602418-1-12-2022-28-AS-SCOL-CCXLEX-20220328084215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 01/12/2022
Date Signed: 01/12/2022 01:21:01 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
01/06/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220106133955

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:	(626) 699-4613
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	80	CENSUS: 34	DATE:	01/12/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lupe Harvey - Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Mangement requires staff to work when diagnosed with covid
Masks are not required
Gloves are not required

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit in response to the above mentioned allegations. LPA met with Administrator Lupe Harvey and explained the reason for the visit.

Investigation consisted of the following: LPA requested a copy of staff and resident rosters, and conducted a tour of facility and common areas. LPA conducted interviews with the administrator, staff #1 - #4 (S1 - S4), and resident #1- #4 (R1 - R4).

The investigation revealed the following: in regards to the allegation "management requires staff to work when diagnosed with covid", it is alleged that a staff who has Covid-19 was told to sleep in the hallway and care for a resident who also has Covid-19. Interviews with administrator and staff revealed that managment does not required staff to work when they test positive for Covid-19. The staff in question was also interviewed and it was found that this staff did not have Covid-19 at any time.
(CONTINUED TO LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

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 2

Control Number 28-AS-20220106133955

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: 01/12/2022

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 staff was asked to sit outside the resident's room and only care for this resident to prevent the spreading Covid-19. The staff also denied sleeping in the hallway and that the shift they work is from 6am to 6pm.

In regards to the allegation "masks are not required", it is alleged that management does not required staff to wear a mask. Interviews conducted with staff revealed that wearing a mask is mandatory at all times while working at this facility. All four of the residents that were interviewed stated that they have observed all staff wearing a mask. During the tour of the facility, LPA Mora observed all staff wearing a mask and the administrator has set up small stations throughout the facility with Personal Protective Equipment (PPE) supplies for the staff.

In regards to the allegation "gloves are not required", it is alleged that management does not required staff to wear gloves. Interviews conducted with staff revealed that using gloves is mandatory when assisting residents. Furthermore, staff have to dispose of the gloves after assisting a resident and wear new gloves when assisting another resident. During the tour of the facility, LPA Mora observed three staff wearing gloves when they were helping a resident move from the wheelchair to the couch.

Reporting party also indicated that staff are not offered sick leave if they are asks to stay home because of Covid-19. Interviews conducted with staff revealed that staff are able to use their own sick leave if they still have a balance. However, the Covid-19 Supplemental Paid Sick Leave is no longer being offered because it expired on September 30th, 2021.

Based on statements and interviews conducted with staff and residents, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was held with Administrator Lupe Harvey and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2