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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 05/02/2023
Date Signed: 05/02/2023 04:00:32 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
04/25/2023 and conducted by Evaluator Ashley Calderon
COMPLAINT CONTROL NUMBER: 28-AS-20230425115536
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: 30DATE:
05/02/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administartor - Lupe HarveyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident wandered away from the facility due to lack of supervision.
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 allegation. LPA met with Administrator Lupe Harvey and explained the reason for the visit.

The investigation consisted of: LPA toured with Harvey the facility and observed exits doors, lobby, hallways, dining area, and outside garden and parking lot.LPA conducted interview with Lupe Harvey, Staff #1, Staff #2 and Staff #3 (S1, S2 and S3). LPA interview Resident #1 (R1), Resident #2 and Resident #3 (R1, R2 and R3). LPA obtained copies of Staff and Resident Rosters, R1 and R2's facesheet, Physican's report, and Special Incident Report (SIR).

Continuation on Page 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023
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 3
Control Number 28-AS-20230425115536
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: 05/02/2023
NARRATIVE
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Regarding allegation: Resident wandered away from the facility due to lack of supervision.
During interview with Administrator, Harvey was informed by staff via telephone that residents were outside and when staff went to look for residents outside residents were not in the facility premises. During interview S1 stated they were informed residents were outside when S1 checked on residents, they were not present and were not aware of residents whereabouts. S2 stated caregivers were preoccupied with residents who wander and when staff checked on resident #1 and #2 outside they were gone. S3 stated residents were in the dining area and after went outside, caregivers were not present, S3 was on break and once caregivers were notified about residents being outside, caregivers checked on residents and they had left facility. Interview with R3 stated staff are on their cellphones and not preforming their duties, R1's family stated facility stated that R1 disappeared and facility did not know where R1 went and left with another resident and they called Monrovia Police Department.

Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D.

Exit interview was conducted with Administrative Assistant Claudia Sanchez. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230425115536
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/31/2023
Section Cited
HSC
1569.2(c)
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Health and Safety Code- Defintions:
1569.2(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
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Licensee /Administrator shall: ensure that all staff are trained on the responsibility of providing care and supervision. Administrator will conduct an in service with all staff, and will provide proof of training to LPA Calderon by POC due date.
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This was not met as evidenced by: Staff were not aware of residents whereabouts. Resident #1 and Resident #2 disappeared and were not on the facility premisis when caregivers went to check on residents.
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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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3