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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603585
Report Date: 05/17/2023
Date Signed: 06/16/2023 02:57:43 PM

Substantiated


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
12/12/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221212100233
FACILITY NAME:HENRIETTA'S HOMEFACILITY NUMBER:
198603585
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 703-4958
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 4DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Belen Taico, ManagerTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Licensee had liability insurance that did not include required coverage for resident’s injuries.
The Licensee has no current liability insurance.
INVESTIGATION FINDINGS:
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***This amended report dated 5/19/2023 supersedes the report dated 5/17/2023. This report is being created to add an additional paragraph to LIC 9099D. Revision does not change complaint findings, and all other complaint report aspects remain in effect.This unannounced subsequent complaint inspection is being conducted by Licensing Program Analyst (LPA) Galarza for the purpose of delivering findings for the investigation into the above identified complaint allegations. The LPA met with facility Manager Belen Taico and explained the reason for today’s inspection.

There was concern that the Licensee representative had liability insurance that did not include the required coverage for resident’s injuries, and that the Licensee representative has no current liability insurance.
On 12/13/2022, LPA Galarza conducted the initial 10-day complaint investigation and conducted interviews from 8:05 a.m. to 3:45 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records. Facility staff stated that this facility had liability insurance with an effective date of 08/26/2022. Further investigation was required.
***See LIC9099C for continuation of the narrative***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20221212100233
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 HOME
FACILITY NUMBER: 198603585
VISIT DATE: 05/17/2023
NARRATIVE
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On 12/14/2022 the LPA reviewed the insurance records for clarification. Licensee presented multiple Certificate of Liability Insurance.

The Certificate of Liability Insurance dated 09/02/2022 for Policy Number ending in 191-0 shows an effective date of 08/26/2022 thru ending date of 8/26/2023. This corroborates with the facility staff’s statement. This certificate indicates the coverage of limits one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. However, this certificate states that this policy is shared by this facility and six (6) other facilities, meaning this policy does not provide the required coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate for this facility.

On 12/6/2022, the Policy Number ending in 191-0 dated 9/2/2022 was rewritten into Policy Number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] and there was no gap between these policies since 08/26/2022 thru ending date of policy of 8/26/23. This is a separate, stand-alone business liability insurance for this facility.

An Insurance Binder dated 12/08/2022 for Policy Number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] identified multiple policy exclusions, including exclusions for “Infestation”, “Bedsores”, “Elopement (General Liability)”, and “Treatment of Coronavirus”. Per witness interview, the exclusion for “Bedsores” means that this policy does not cover resident injuries due to bedsores if there is evidence of negligence on the part of the Licensee. Witnesses also stated that the exclusions for “Infestation” and “Elopement (General Liability)” mean that the Licensee is not responsible for obtaining insurance for injuries to residents from infestations and elopements. Due to the exclusions, this policy does not include the required coverage for resident injuries caused by the negligent acts or omissions to act of, or neglect by, the Licensee or its employees.


The Certificate of Liability Insurance dated 12/13/2022 for policy number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] shows an effective date of 12/06/2022.



***See LIC9099C for continuation of the narrative***
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20221212100233
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 HOME
FACILITY NUMBER: 198603585
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/24/2023
Section Cited
CCR
1569.605
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Liability insurance… all residential care facilities for the elderly … 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. This requirement was not met as evidenced by:
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Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date (05/24/23).
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Based on liability insurance records reviewed, interviews conducted with Administrator and relevant witnesses, it was determined that the licensee did not have required liability insurance coverage for 08/26/2022 to present which poses an immediate safety risk to residents in care.
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Request Denied
Type A
05/24/2023
Section Cited
CCR
1569.605
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CONTINUATION OF ABOVE
Based on interviews and records review, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts specified which posed a potential Health, Safety, or Personal Rights risk to 4 persons in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 28-AS-20221212100233
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 HOME
FACILITY NUMBER: 198603585
VISIT DATE: 05/17/2023
NARRATIVE
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Based on the investigation conducted by the Department it was determined that between 08/26/2022 and 12/06/2022, this facility did not have its own liability insurance coverage that is compliant with Title 22 Regulations, licensee has no current liability insurance. As a result, the above-mentioned allegations are being substantiated. Please see LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4