198603586-8-31-2023-28-AS-TVAO-CVDN47-20230905100726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 08/31/2023
Date Signed: 08/31/2023 09:42:59 AM

Unsubstantiated

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
01/20/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230120090838

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: 39	DATE:	08/31/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Claudia Sanchez, Staff		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Questionable death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to render the finding for the allegation of a questionable death. LPA met with Staff, Claudia Sanchez, and explained the purpose of the visit.

The investigation consisted of the following:
On 1/20/23, LPA Chan obtained copies of the staff and resident rosters. LPA toured the facility, inside and out, and inspected random rooms: #1, #4, #7, #10, #12, #15, and #30. There were no immediate health and safety concerns noted. Sufficient food supplies for the current resident census were observed. LPA requested for documents for 4 residents. On 4/28/23, LPA Chan conducted another visit to interview the Administrator, 4 Staff, and 2 Residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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-20230120090838

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	FACILITY NUMBER: 198603586
	VISIT DATE: 08/31/2023

NARRATIVE

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The investigation revealed the following:
Regarding allegation of questionable death, it was alleged that a staff member (S-1) provided drugs to Resident #1 (R-1) which resulted in resident passing.
Interviews with staff indicated that R-1 was self responsible, did not need assistance with activities of daily living, and often left the facility during the daytime. R-1 was able to leave the facility unassisted as noted in the physician’s report. Staff did not witness any staff giving R-1 drugs, however, one staff found substances once in R-1’s room. Staff questioned R-1 about the drug and how it was obtained but the resident did not state who provided it. Although staff could not confirm R-1 used drugs, they did observe R-1 returning to the facility intoxicated, more often prior to the death. They attempted to intervene by offering services to R-1, however, R-1 would become agitated and aggressive whenever staff reached out. R-1 passed away on 1/17/23. According to the coroner’s medical report, the immediate cause of death was due to arteriosclerotic cardiovascular disease and was determined as a natural cause. Based on the information gathered, the allegation of a questionable death for Resident #1 (R-1) was unsubstantiated.

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 allegation is UNSUBSTANTIATED.

An exit interview was conducted with Ms. Sanchez. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC9099 (FAS) - (06/04)

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