198602418-8-10-2022-28-AS-WSHO-CHCQY3-20220816123427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:41:57 PM

Unsubstantiated

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
08/01/2022 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220801170740

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: 28	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Lupe Harvey; Administrator		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Resident was hit while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Lupe Harvey and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA also interviewed the Administrator, Staff #1 - Staff #3, and Resident #1 - Resident #6. LPA obtained copies from Resident #1 (R1) file such as Physician's Report, Identification and Emergency Information Sheet, Preplacement Appraisal and Appraisal, Special Incident Report, and Facility Sign In Sheet.

The investigation revealed the following: in regards to the allegation "resident was hit while in care", it is alleged that on 07/22/22 Resident #1 (R1) was sleeping in his room and was woken up by slaps on the side of his face. R1 allegedly indicated there were two people in the room speaking in Korean, but was unable to see who the individuals were before they left. Interview with R1 revealed that he's unsure if the alleged perpetrator/s were male or female. R1 also indicated during interview that he's unsure if the incident was a dream or real.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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-20220801170740

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: 08/10/2022

NARRATIVE

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Interviews conducted with staff members indicated they did not witness the alleged incident. Staff members interviewed indicated they have never hit any of the residents. Interviews conducted with residents indicated they did not witness the alleged incident. Residents interviewed indicated they have never been hit by any staff member or other residents. Additionally, R1 does not have a roommate and R1 could not identify possible perpetrator/s. There were no witnesses, camera footage, or evidence obtained during the investigation to corroborate with the allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC9099 (FAS) - (06/04)

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