198602418-8-24-2023-28-AS-WSHO-CWC2DB-20231005171802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602418
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:34:10 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
07/21/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220721145246

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:	0	CENSUS: 0	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	01:54 PM
MET WITH:	Madilyn Sanchez / Medical Technician		TIME COMPLETED:	02:48 PM

ALLEGATION(S):

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Staff failed to report incident.
Staff failed to notify.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced follow up visit to this facility to assist Licensing Program Analyst (LPA) Joe Katrdzhyan with delivering findings on the above-mentioned allegations of "Staff failed to report incident and Staff failed to notify”. Upon arriving at the facility, LPA met with Madilyn Sanchez / Medical Technician who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 7/21/22, in reference to the allegations listed above.

During the course of the investigation, interviews were conducted of various persons to include the Administrator/Facility Manager, Staff members 1 - 4 (S1 - S4) and Resident 1 (R1). During the visit conducted on 7/21/22, LPA observed the Administrator conduct the antigen test on R1.

(Continued to LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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-20220721145246

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 08/24/2023

NARRATIVE

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The investigation revealed the following:

Allegations: Staff failed to report incident and Staff failed to notify.
Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the above-mentioned allegations. LPA discovered that on 7/20/22, facility staff and residents were tested for COVID-19 using the antigen test kits. Staff interviewed denied being notified by facility management about R1’s test results. On 7/20/22, S1 was overheard by other staff in the dining room telling R1 that “you know you’re not supposed to be down here because you have COVID”. On 7/21/22, LPA Katrdzhyan conducted a complaint visit to this facility in reference to the allegations listed above. Interviews were conducted with the Administrator and S1 and both failed to disclose that R1 tested positive for COVID-19. At 4:45pm, LPA requested the Administrator to test R1 for COVID-19, using the antigen test kit. LPA observed the test and the results for R1 came back positive for COVID-19. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Based on the information gathered, it was determined that Facility Management failed to inform residents, staff, CCL and DPH about the positive COVID-19 case involving R1. This poses an immediate health, safety or personal rights risk to persons in care, staff and LPA.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are 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 to the facility along with the Appeals Rights.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220721145246

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 08/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/25/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by:	1 2 3 4 5 6 7	Administrator will review Title 22 Regulations Section 87468.1 on Personal Rights of Residents in All Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
	8 9 10 11 12 13 14	Statements obtained from staff and R1 confirmed that R1 tested positive for COVID-19 on 7/20/22. On 7/20/22, S1 was overheard by other staff in the dining room telling R1 that “you know you’re not supposed to be down here because you have COVID”. Staff interviewed denied being notified by facility management about R1’s test results. On 7/21/22, LPA Katrdzhyan conducted a complaint visit to this facility in reference to the allegations listed above. Interviews were conducted with the Administrator and S1 and both failed to disclose that R1 tested positive for COVID-19. At 4:45pm, LPA requested the Administrator to test R1 for COVID-19, using the antigen test kit. LPA observed the test and the results for R1 came back positive for COVID-19. Facility Management failed to inform residents, staff, CCL and Department of Public Health regarding the positive COVID-19 case involving R1. This poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 08/25/2023 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not being met as evidenced by:	1 2 3 4 5 6 7	Administrator will review Title 22 Regulations Section 87211 on Reporting Requirements and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
	8 9 10 11 12 13 14	Statements obtained from staff and R1 confirmed that R1 tested positive for COVID-19 on 7/20/22. On 7/20/22, S1 was overheard by other staff in the dining room telling R1 that “you know you’re not supposed to be down here because you have COVID”. Staff interviewed denied being notified by facility management about R1’s test results. On 7/21/22, LPA Katrdzhyan conducted a complaint visit to this facility in reference to the allegations listed above. Interviews were conducted with the Administrator and S1 and both failed to disclose that R1 tested positive for COVID-19. At 4:45pm, LPA requested the Administrator to test R1 for COVID-19, using the antigen test kit. LPA observed the test and the results for R1 came back positive for COVID-19. Facility Management failed to inform residents, staff, CCL and DPH about the positive COVID-19 case involving R1. This poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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