198603586-3-9-2023-28-AS-FFIS-CU5S37-20230727133036

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 03/09/2023
Date Signed: 03/09/2023 02:55:57 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
02/28/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230228144829

FACILITY NAME:	HENRIETTA'S LEVEN OAKS		FACILITY NUMBER:	198603586
ADMINISTRATOR:	HARVEY, LUPE		FACILITY TYPE:	740
ADDRESS:	120 S. MYRTLE AVENUE		TELEPHONE:	(213) 478-0460
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	80	CENSUS: 28	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator Lupe Harvey		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not assist resident with toileting
Staff locked resident in bathroom
Facility is not providing a safe environment for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint visit to gather information pertaining to the above mentioned allegations. LPA met with Assistant Administrator Claudia Sanchez and shortly after met with Administrator Lupe Harvey and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Assistant Administrator Claudia Sanchez , Administrator Lupe Harvey, Staff #1 and Staff #2 (S1 and S2). LPA attempt to interview Resident #1 (R1) and R1's roommate resident #4 (R4) and was unsucessful. LPA interviewed Resident #2 and #3 (R2 and R3). LPA obtained copies of Staff and Resident Rosters, R1's facesheet, Physican's report, Pre-Apprasial, Apprasial Needs and Service Plan, Resident Appraisal, and Special Incident Report (SIR). LPA alongside with Lupe Harvey toured two floors,common resident restrooms located only on first floor, common areas like dinning/acitivity room,gardens/patios, lobby room, and residents rooms: Room #4, R1's Room #8, Room #10, Room #22 and Room #32. LPA tested call syatem button in room #4, room #5, and room #32.
Continuation on Page 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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-20230228144829

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	FACILITY NUMBER: 198603586
	VISIT DATE: 03/09/2023

NARRATIVE

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Based on today's investigation record review, observations and interviews by LPA Calderon.

The investigation revealed in regards to allegation: Staff do not assist resident with toileting. LPA interview with Lupe, Claudia, S1 and S2 all who denied the above allegation stating residents get assistance as needed and caregivers do their rounds every 2 hours. LPA Calderon interviewed R2 and R3 who stated are incontinence residents staff help with toileting needs and denied the above allegation. LPA Calderon observed Caregiver staff responding in a timely manner when call system in residents rooms were pushed, room #4, room #5, and room #32.

Investigation revealed in regards to allegation: Staff locked resident in bathroom. LPA Calderon interview Lupe, Claudia, S1 and S2 and all denied the above allegation starting resident(s) are not locked in restroom. LPA interview R2 and R3 and denied they do not get locked in restrooms and not aware of others being locked. LPA observed R1's room and first floor common restrooms door / knobs which has no ability lock to from the outside to lock residents in restrooms.

Investigation revealed in regards to allegation: Facility is not providing a safe environment for residents. LPA Calderon interview Lupe, Claudia, S1 and S2 and denied the above allegation stating facility is a safe place for residents in care. LPA Calderon interview R2 and R3 who denied the above allegation and stated facility is a safe environment. LPA Calderon review a SIR pertaining to R1's safety, facility providing R1 with medical assistance for R1's mental health and safety needs. LPA Calderon observed common areas inside and outside and resident's rooms. Facility was free of hazard, safe with ramps, handle bars/ grab bars, pathways were clear and free of obstructions, open space, exit doors had alarm system, adequate lighting and operating call systems in residents rooms.

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 allegations are UNSUBSTANTIATED.

Exit interview held and copy of the report was provided to Administrator Lupe Harvey.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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