198603586-9-26-2023-28-AS-ACAN-CW2VE8-20230926162155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:23:29 PM

Document Has Been Signed on 09/26/2023 04:23 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 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: 35	DATE:	09/26/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Interm-Administrator Claudia Sanchez		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Calderon, made a unannounced annual continuation case management visit. LPA met with interm-Administrator Claudia Sanchez and discussed the purpose of today's visit.The facility is licensed to serve: Elderly residents ages 60 and over. Approved for (48) ambulatory residents and (32) non-ambulatory residents. (7) non-ambulatory can be bedridden. Bedroom # B1,A2,4,5,8,9,12 are cleared for bedridden residents. During today's visit LPA used the CARE Inspection Tool to continue the 1 year required annual inspection, LPA reviewed medication for (3) residents and reviewed centralized medication log. No deficiency noted for medication review. LPA Calderon did staff file review for, a total of (5) files, five files were reviewed. LPA checked for clearance, personnel records, health screening, training and first aid/ cpr certification. During file record review the following was observed and cited: 1) Personnel records- for Staff # S3 did not contain a job application nor an LIC 501 personnel record and no physician health screening / tb report LIC 503 - Interm-Admin. Claudia Sanchez assisted LPA Calderon in locating documentation's and documentation's were not in S3 file. (2) Deficiency cited. 2) No clearance record for Staff #1(S1), LPA Calderon called LPM Fierros and Licensing Support Staff to verify clearance of S1, LIS did not contain records of S1 on the system, Facility Interm-Admin. Claudia Sanchez was unable to get record of S1 clearance status. Deficiency and Civil Penalty cited. LPA was will return on a later time to complete annual inspection. LPA will sent reports 809, (2) 809-D pages, Civil Rights, and Appeal Rights to Interm-Administrator Claudia Sanchez via email. Due to printer issues.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 04:23 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance 87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Calderon and Interm-Administrator Claudia Sanchez record review Staff 1 (S1) did not have clearance record , doj response and was not associated on LIS/ Guardian, no records of clearance record for S1 on file, the licensee did not comply with the section cited above in 35 out of 35 residents/ persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	Interm-Administrator Claudia Sanchez notified LPA Calderon that she will be making the decision for Staff 1 (S1) to end shift today on 9/26/23 as S1 is on schedule and facility is waiting fingerprint status and will wait for clearance and will get S1 associated prior for S1 return to the above facility. Interm-Administrator Claudia Sanchez notified LPA that S1 went to get fingerprints on 9/25/23. Interm-Administrator Claudia Sanchez will sent LPA Calderon proof of S1 Clearance Status and Association via Guardian once cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 04:23 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Calderon and Interm-Administrator Claudia Sanchez for staff #3 (S3) record review S3 did not have helath screening / tb in staff file upon review, the licensee did not comply with the section cited above in 35 out of 35 residents/ persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Interm-Administrator Claudia Sanchez during LPA's visit informed S3 to obtain health screening form the Clinic. Interm-Administrator Claudia Sanchez will obtain documenation and provide LPA Calderon with a copy via email by POC date.

Type B

Section Cited

CCR

87412(a)(7)

Personnel Records 87412(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (7) Past experience, including types of employment and former employers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Calderon and Interm-Administrator Claudia Sanchez for staff #3 (S3) record review S3 did not have job application or personnel record in staff file upon review, the licensee did not comply with the section cited above in 35 out of 35 residents/ persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Interm-Administrator Claudia Sanchez for staff #3 (S3) will provide S3 with LIC501 or Job App to complete, once completed Claudia Sanchez will provide LPA Calderon a copy via email by POC date.

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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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