198602418-6-2-2022-28-AS-SCOL-CFSU9W-20220627152348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:43:36 PM

Substantiated

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
05/25/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220525122002

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: 32	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Med Tech / Claudia Sanchez Facility Manager / Lupe Harvey		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility has pests.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Med Tech / Claudia Sanchez and was later joined by the Facility Manager / Lupe Harvey who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Facility has pests."

During today's visit, LPA interviewed the Facility Manager, Staff members 1 through 4 (S1 - S4) and Residents 1 through 4 (R1 - R4). LPA made multiple attempts to interview Staff 5 (S5) via telephone but was unsuccessful as S5 did not answer or return calls. A tour of the kitchen was also conducted. The facility Manager provided a copy of an invoice from Western Exterminator Company.

The investigation revealed the following;
Allegation: Facility has pests. The details of this allegation states that about a month ago, rats were observed in the kitchen. (please see LIC 9099C for additional information)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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-20220525122002

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: 06/02/2022

NARRATIVE

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Based on interviews conducted the statements obtained were consistent and corroborated with the allegation. Interviews confirmed that rats have been observed inside the kitchen, running underneath the dishwasher and also eating food left out on kitchen counters. Rats have also been observed running inside in the hallway, near the kitchen. At 9:56am, LPA toured the facility kitchen and observed a large (heavy duty) rat/mouse rodent pest glue trap, located underneath the kitchen counter (in front of the oven). According to the Facility Manager, the facility had concerns of rodents being present inside the facility in the past. Based on the visit made by Western Exterminator Company (WEC) on 5/10/22, it was noted on the invoice that the facility has had ongoing issues with rodents.

1/3/19 - Building needs rodent proofing.
4/2/19 - Doors left open. Door to be closed properly to keep pests from entering the structure.
11/5/19 - Pest rodent proofing is needed - fix broken vents.
4/26/21 - Pest rodent proofing is needed - fix broken vents. Fix all holes around property.
9/29/21 - Overgrown vegetation - Provides harborage and ides the movement of pests. Limits inspection access and interferes with treatment. Cut back vegetation 18 to 24 inches from structure.

Most of the items listed above were reviewed by WEC on 4/26/22. Based on interviews conducted, LPA's observation and record review, there is sufficient evidence to support this allegation to be true.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220525122002

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: 06/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/16/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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 being met as evidenced by:	1 2 3 4 5 6 7	Administrator will maintain a contract with a licensed pest control extermination company for pests and provide a copy of the contract to CCL outlining a revised approach to eradicate the ongoing issue of pests. POC must be submitted to CCL by the POC due date.
	8 9 10 11 12 13 14	Statements obtained confirmed that rats have been observed inside the kitchen, running underneath the dishwasher and also eating food left out on kitchen counters. Rats have also been observed running inside in the hallway, near the kitchen. Based on the invoice from Western Exterminator Company, it was noted that the facility has had ongoing issues with rodents.	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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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