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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 08/26/2022
Date Signed: 08/26/2022 02:08:44 PM


Document Has Been Signed on 08/26/2022 02:08 PM - 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 OAKSFACILITY NUMBER:
198603586
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:120 S. MYRTLE AVENUETELEPHONE:
(213) 478-0460
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 28DATE:
08/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive Director / Lupe Harvey
Director of Assisting Living Operations / Stephany Perez		TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an announced follow up to the pre-licensing inspection conducted on 8/23/22. Licensee / Specialized Community Healthcare Company., has submitted an application to operate a Residential Care Facility for the Elderly for a capacity of eighty (80) residents, ages 60 and over. Since the initial pre-licensing inspection conducted on 8/23/22, Licensee has obtained a revised STD 850 / Fire Safety Inspection Request Form. The facility now has an approved fire clearance for forty eight (48) ambulatory residents, twenty five (25) non-ambulatory residents and seven (7) bedridden residents only. According to the STD 850 / Fire Safety Inspection Request Form, All Non-ambulatory residents must reside on the first floor of the facility and ONLY Ambulatory residents shall reside on the second floor. Rooms for bedridden residents = B1, A2, 4, 5, 8, 9 and 12. The new application is being processed as a change of ownership. There are currently twenty eight (28) residents living at the facility. There are two (2) bedridden residents residing at the facility. Henrietta's Leven Oaks has a Dementia Care Program and will be accepting and caring for residents with dementia, upon licensure.

During today's visit, LPA toured the facility and the following concerns below remain outstanding and need to be corrected prior to licensure;
  • There is a pending item listed on the STD 850 / Fire Safety Inspection Request Form which will need to be addressed prior to licensure. STD 850 dated 8/25/22 states, "Final Fire Safety Approval Is Pending Building Dept. Approval Of Main Staircase / Egress Because Of Stair Chair Installed Without A Permit".
  • Rooms 8 and 7 share a bathroom and the bathroom is missing a bathroom door.
  • Room 1 is missing a bathroom door.
  • The hot water temperature in room 24 was measured at 122.4 degrees F.
  • Room 24 and 25 share a bathroom and the bathroom is missing a bathroom door.
  • The hot water temperature in room 35 was measured at 104.5 degrees F.
  • Room B2 (located in the cottage) is missing a bathroom door.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
FACILITY NUMBER: 198603586
VISIT DATE: 08/26/2022
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Applicant understands that all concerns listed on this report will need to be corrected prior to licensure.
Once Applicant has made corrections, LPA will return on a future date for a final inspection, ensuring facility is in compliance and ready for licensure.

Component III was conducted during today's visit.

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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2