198603586-9-25-2023-28-AS-ACAN-CVZU4Y-20230925151552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 09/25/2023
Date Signed: 09/25/2023 03:16:12 PM

Document Has Been Signed on 09/25/2023 03:16 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:	09/25/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Interm-Administrator Claudia Sanchez		TIME COMPLETED:	03:20 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. LPA used the CARE Inspection Tool for the required one year annual inspection. Today's inspection consisted of: LPA Calderon along side with Interm-Administrator toured the inside and outside of the facility. The facility consist of: Random resident bedrooms and bathrooms were observed: Room #4, Room B-1A, Room B-1B, Room #6, Room #25 and Room #33. Resident bedrooms were equipped with a bed, chair, night stand, adequate lighting and ample closet/storage space for each resident. Appropriate linens and towels were observed and extras stored in hallway closet in the main building. Laundry room with washers and dryers were observed. Bathrooms are clean and operational with non-skid mats. Water tested within Title 22 regulations, measuring between 105F to 120 F. Appropriate food supply of two days of perishables and seven (7) days of non-perishables. Thermometers in place, kitchen appliances were operable and food menu in place. Sharps are locked in the kitchen, kitchen is inaccessible to resident in care. Continuation on 809-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

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
	VISIT DATE: 09/25/2023

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
26
27
28
29
30
31
32

Resident and staff records are centrally stored and locked in the Executive Director's office.
Functioning telephone on the premises.
Cleaning solutions, disinfectants, and chemicals were left out in the cleaning cart found unattended near building B, cleaning products were found accessible to residents in care. Deficiency noted.
Emergency Disaster Plan, Personal Rights, Labor Laws, Licensing and Ombudsman and Facility Sketch were observed posted.
Facility has storage room with code lock located in dining room area with hygiene supplies and cleaning product supplies kept locked.
Fire place kept adequately screened.
Fire extinguishers charged and placed throughout the facility, fire alarm pull system connected to the Fire Dept of Monrovia, smoke detectors and carbon monoxide tested and operable.
Fire Drill conducted on: 6-16-23.
Outside areas was observed to have multiple areas with shade and maintained landscaped. LPA observed patio deck containing (4) ripped chairs and ladder left in patio leading to the roof top. Shed with storage items, shovel and oxygen tanks left unlocked and accessible to clients in care. Facility has spider webs and dirt on railings, in the patio roof awnings in Building B and patio next to dining room. Outside patio has spider webs, dirt and debris on outside furniture(s) chairs, bbq, table and awning. Deficiency noted.
Facility liability insurance expires: 8/26/2024.
LPA will returned on a later date to complete annual inspection facility.

Deficiencies were cited on 809-D, this report was provided to interm-Administrator Claudia Sanchez. An exit interview was conducted and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/25/2023 03:16 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: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Calderon and Interm-Administrator Claudia Sanchez observations, the following was observed: cleaning solutions, disinfectants, and chemicals were left out in the cleaning cart found unattended near building B, cleaning products were found accessible to residents in care. The licensee did not comply with the section cited above in 35 out of 35 persons/ residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/26/2023
	Plan of Correction
1 2 3 4	Interm-Administrator Claudia Sanchez immediately locked cart in a closed off locked area. Facility will provide LPA Calderon with an in-service training material and staff sign in sheet regarding Title 22 Section 87309, to be submitted to LPA by 10/6/23.

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: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/25/2023 03:16 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: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Calderon and Interm-Adminstrator Claudia Sanchez observations the following was observed. Patio deck was found to have (4) ripped chairs and ladder left in patio leading to the roof top. Shed with storage items, shovel and oxygen tanks left unlocked and accessible to clients in care. Facility has spider webs and dirt on railings, in the patio roof awnings in Building B and patio next to dining room. Outside patio has spider webs, dirt and debris on outside furniture(s) chairs, bbq, table and awning. , 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	Administrator will provide a in-service training on Section 87303 and provide LPA Calderon with in-service training topic materials, sign in sheet to LPA by POC due date. Facility will provide LPA with images of cleaned awenings, cleaned patio(s) furiture, locked latch for shed.

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: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4