198603586-8-30-2023-28-AS-RORN-CVLNKH-20230912103158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 08/30/2023
Date Signed: 08/30/2023 05:07:53 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 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:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Substitute Administrator- Stephany Perez		TIME COMPLETED:	05:15 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 a complaint visit to deliver report that supersedes report dated 5/02/23. LPA met with Substitute Administrator Stephany Perez and Claudia Sanchez and explained the reason for the visit.

On 5/02/23 initial 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 face sheet, Physician's report, and Special Incident Report (SIR).

Continuation on Page 9099-C...

Substantiated

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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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-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: 08/30/2023

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 on 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. S1 was informed by kitchen staff who was on her break that the residents had eloped; the residents eloped through the back gate that was known by staff to sometimes be open/unlocked; after review of records, it was determined that both residents were not able to leave the facility unassisted; and that during the visit the signal system was tested/working. Residents were both found and returned to the facility.

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 Substitute Administrator- Stephany Perez . A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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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: 08/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/15/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705(c)(4) Care Of Persons With Dementia: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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