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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 05/19/2022
Date Signed: 05/19/2022 12:41:32 PM


Document Has Been Signed on 05/19/2022 12:41 PM - 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: 32DATE:
05/19/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Med Tech / Claudia SanchezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPA met with Med Tech / Claudia Sanchez who assisted with the visit.

During today's visit, a copy of the current resident roster was obtained. LPA obtained the Emergency Contact Information / Identification and Emergency Information for Residents 1 - 4 (R1 - R4). LPA spoke with R1 - R4 and provided an update regarding the Decision and Order and a copy of the Stipulation #6120010302E was provided to R1 - R4.


Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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