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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 08/31/2022
Date Signed: 06/07/2023 09:57:57 AM

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
08/25/2022 and conducted by Evaluator Joe Katrdzhyan
COMPLAINT CONTROL NUMBER: 28-AS-20220825120230
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:
08/31/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Facility Manager / Lupe HarveyTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Resident engaged in a physical altercation with another resident in care.

Staff refused to seek medical attention for resident.
INVESTIGATION FINDINGS:
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***This is an amended report which supersedes the original report dated 8/31/22. The purpose of this report is to remove confidential information and make corrections on report. The amendments to the report do not affect or change the findings on this complaint.***

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Facility Manager / Lupe Harvey who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Resident engaged in a physical altercation with another resident in care" and "Staff refused to seek medical attention for resident".

During today's visit, LPA interviewed the Facility Manager, Staff members 1 and 2 (S1 and S2) and Residents 1 - 4 (R1 - R4). Also, copies of the following documents were obtained and reviewed in reference to R1; (Please see LIC 9099C for additional information)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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-20220825120230
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: 08/31/2022
NARRATIVE
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• Identification and Emergency Information Sheet • Resident Appraisal • Preplacement Appraisal Information • Physician's Report • Unusual Incident/Injury Report • Physician's Report for R2 • Medical Report from Foothill Presbyterian Hospital (FPH)

The investigation revealed the following;

Allegations: Resident engaged in a physical altercation with another resident in care and Staff refused to seek medical attention for resident. The details of these allegations state that there was a physical altercation involving R1 and R2, and R2 struck R1 on the head, both cheeks/face and on his stomach. R2 has also poured water on R1's head in the past. R1 asked to go to the E.R. but staff refused.

Based on interviews conducted the statements obtained were inconsistent and did not corroborate with these allegations. LPA discovered that the alleged incident occurred on 8/8/22, sometime in the AM (exact time unknown) between R1 and R3 and R1 was the aggressor during the incident.
During the interview of R1, R1 stated that his Roommate / R3 punched him on his head, face and chest. There were no witnesses to the alleged incident. R1 stated that he requested to be sent to the hospital after the alleged incident and facility staff called the paramedics and R1 was transferred to Foothill Presbyterian Hospital (FPH) in Glendora, for an evaluation. According to R1, he did not sustain any injuries and after being evaluated at the hospital, R1 was released back to the facility a few hours later. R1 also alleged that R3 has poured water on him in the past but there have been no witnesses to the alleged incident. During the interview of R3, LPA was unable to obtain information related to the alleged incident based on R3's cognitive skills. During the interview of R2, R2 denied ever engaging in a physical altercation with R1.
Interviews conducted of staff confirmed that R1 was the aggressor during the incident involving R3 and R1 was observed swinging his belt at R3, striking R3 on the hand (unknown which hand). Facility staff conducted a body check of R1 and found no sign of bruising or injuries. Staff also conducted a body check of R3 and found bruising on the hand of R3, as a result of being struck by R1 (using the belt). R1 complained to staff of having chest pain and was also observed having self injurious behaviors, such as purposely throwing himself off his wheelchair and onto the floor. Staff confirmed that R1 was taken to FPH for an evaluation and released shortly after, on the same day. The Monrovia Police Department was involved and conducted interviews with R1, R2 and facility staff but no further action was taken. Although it appears an altercation did occur between R1 and R3, staff intervened immediately, conducted body checks, and
called the Police and R1’s case worker. Paramedics were also called at R1’s request. Therefore, there is insufficient evidence to indicate a lack of supervision on the part of the facility. Based on the information gathered, there is insufficient evidence to support the above allegations to be true.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
An 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: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
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