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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602418
Report Date: 08/16/2022
Date Signed: 08/16/2022 09:34:31 AM


Document Has Been Signed on 08/16/2022 09:34 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:
08/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Med Tech / Claudia SanchezTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction citation issued during the 7/13/22 case management visit. Upon arriving at the facility, LPA met with Med Tech / Claudia Sanchez who assisted with the visit. The purpose of this visit was explained.

On 7/13/22 the facility was cited for:

HSC ยง1569.605 Liability insurance; coverage requirements - On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

Licensee failed to submit plan of correction proof of liability insurance to CCL on POC due date 7/15/22. Civil Penalties are being issued for period 8/3/22 - 8/16/22. Total of 14 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $1,400.00.


Deficiencies are cited per Health & Safety Code Sections 1569.605.
LPA explained the citations, civil penalty assessment, and appeal rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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