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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 08/02/2022
Date Signed: 08/02/2022 10:26:00 AM


Document Has Been Signed on 08/02/2022 10:26 AM - 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: 28DATE:
08/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. During a Plan Of Correction (POC) visit conducted on 8/2/22, the following concerns were observed upon entering the facility;

At 9:35am, LPA was greeted by Staff #1 (S1) and S1 was observed not wearing a face covering/mask, while working inside the facility (inside common bathroom). Also, LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care. During this visit, LPA discovered that Henrietta's Leven Oaks by Serenity Care Health has currently one (1) COVID positive resident in isolation.

The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Facility Manager along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/02/2022 10:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2022
Section Cited

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Infection Control Requirements. In addition to subsection (a), when one or more residents in the facility are diagnosed with a communicable disease, the following shall apply:
All staff and volunteers providing direct care to a resident who has a communicable disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to
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infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.
This requirement is not met as evidenced by:
At 9:35am, LPA was greeted by Staff #1 (S1) and S1 was observed not wearing a face covering/mask, while working inside the facility (inside common bathroom). Also, LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care. During this visit, LPA discovered that Henrietta's Leven Oaks by Serenity Care Health has currently one (1) COVID positive resident in isolation.
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attendees along with the topics covered during the in-service training to CCL, by the POC due date.

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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) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2