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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 09/20/2023
Date Signed: 09/25/2023 09:33:54 AM


Document Has Been Signed on 09/25/2023 09:33 AM - 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 OAKSFACILITY NUMBER:
198603586
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:120 S. MYRTLE AVENUETELEPHONE:
(213) 478-0460
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 33DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Interm-Administrator Claudia SanchezTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Ashley Calderon, made a unannounced annual 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.

LPA will be using the CARE Inspection Tool for the required one year annual inspection.

On today's visit, LPA Calderon interviewed (3) residents and (3) staff personnel's.

LPA will continue annual visit at a further time do time constraint.

No deficiencies noted. An exit interview was conducted with Interm-Administrator Claudia Sanchez and a copy of this report will be sent via email.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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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