198603586-8-23-2022-28-AS-JKAN-CHKVP7-20220823163615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 08/23/2022
Date Signed: 08/23/2022 04:36:27 PM

Document Has Been Signed on 08/23/2022 04:36 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: 28	DATE:	08/23/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director / Lupe Harvey Director of Assisting Living Operations / Stephany Perez		TIME COMPLETED:	04:45 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 Analysts (LPAs) Joe Katrdzhyan and Glenn Truman conducted an announced pre-licensing visit. LPAs met with Executive Director / Lupe Harvey and Director of Assisting Living Operations / Stephany Perez for the purpose of conducting a pre-licensing inspection. Licensee / Specialized Community Healthcare Company., has submitted an application to operate a Residential Care Facility for the Elderly for a capacity of eighty (80) residents, ages 60 and over. The facility has an approved fire clearance for forty eight (48) ambulatory residents, twenty seven (27) non-ambulatory residents and five bedridden residents only. According to the STD 850 / Fire Safety Inspection Request Form, All Non-ambulatory residents must reside on the first floor of the facility and ONLY Ambulatory residents shall reside on the second floor. Rooms for bedridden residents = 4, 5, 8, 9 and 12. The new application is being processed as a change of ownership. There are currently twenty eight (28) residents living at the facility. There are two (2) bedridden residents residing at the facility. Henrietta's Leven Oaks has a Dementia Care Program and will be accepting and caring for residents with dementia, upon licensure. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The building is located in Old Town Monrovia. The main building consists of two floors, there is a detached apartment in the back with 2 rooms located on the first floor and 3 rooms located on the second floor along with two detached cottages. The first floor in the main building consists of a kitchen, dining room, living room/television room, reception/office area, conference room, laundry room and resident rooms. The second floor of the main building consists of resident rooms. LPAs observed a fully equipped living room and a dining room with sufficient dining capacity. Resident bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Resident bedrooms were equipped with a bed, chair, night stand, adequate lighting and ample closet/storage space for each resident. The bathrooms are clean and operational with non-skid mats. The kitchen was observed for

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

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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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: 08/23/2022

NARRATIVE

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the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups is adequate. During today's visit, LPAs observed an appropriate food supply of two days of perishables and seven (7) days of non-perishables. The facility is equipped with a centralized sprinkler system. The main building has a central AC and heating system. The detached apartment in the back along with the two detached cottages all have individual AC units inside resident bedrooms. The front grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the back yard. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises.

Medications and First Aid Kit will be centrally stored and locked in the medication room, located near the dining area. First aid kit is fully stocked with a manual. Resident and staff records are centrally stored and locked in the Executive Director's office. Residents P&I monies are also centrally stored and locked in the Executive Director's office. No firearms will be kept at the facility. Each resident room is equipped with a smoke detector. The facility smoke detectors were tested at the time of this visit. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. There is a functioning telephone on the premises. The hot water temperature was tested throughout the facility. All toxins such as cleaning solutions and detergent soap are also locked in the storage room.
LPA observed the Emergency Disaster Plan, Personal Rights and Facility Sketch posted inside the facility as mandated by Title 22 Regulations.

The following concerns were observed during today's visit;

Per the physician's Report dated 6/9/21, Resident 1 (R1) is listed as non-ambulatory and is residing on the second floor (main building), in room 30.
Per the physician's report dated 8/23/22, Resident 2 (R2) is listed as bedridden and is residing in room B1 (located in the cottage).
Per the physician's report dated 8/1/22, Resident 3 (R3) is listed as bedridden and is residing in room A2 (located in the detached apartment).
Physician's Report for Resident 4 (R4) is incomplete/missing pages.
There is a pending item listed on the STD 850 / Fire Safety Inspection Request Form which will need to be addressed prior to licensure. STD 850 states “Final Fire Safety Approval is Pending Building Dept Approval of Main Staircase/Egress”.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC809 (FAS) - (06/04)

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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: 08/23/2022

NARRATIVE

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The facility elevator is inoperable. Facility will need to obtain a letter from Department of Industrial Relations clarifying whether or not the facility needs to have an operable elevator inside the building.
Room A5 is missing window screens (one on main window and another one on the bathroom window).
The hot water temperature in room 12 was measured at 120.3 degrees F.
Rooms 9 and 10 share a bathroom and the bathroom door is missing a privacy lock. Room 9 is also missing a privacy lock preventing someone from entering the room, through the shared bathroom.
Rooms 8 and 7 share a bathroom and the bathroom is missing a door. Room 8 is also missing a privacy lock preventing someone from entering the room, through the shared bathroom.
Rooms 5 and 6 share a bathroom and the bathroom door is missing a privacy lock.
Room 1 is missing a bathroom door. LPA was unable to test the hot water temperature as there was no hot water coming from the faucet. While the cold water was running, LPA observed the sink was filling up as the water was not draining properly.
Room 24 had no water coming from the faucet and was missing a bathroom door.
The hot water temperature in room 35 was measured at 102.1 degrees F. While the hot water was running, LPA observed the sink was filling up as the water was not draining properly.
Rooms 26 and 27 share a bathroom and room 26 was missing a privacy lock preventing someone from entering the room, through the shared bathroom.
Room B2 (located in the cottage) is missing a bathroom door.
Room A2 (located in the detached apartment) had water leaking from the wall AC unit. The water was leaking on the cord of the AC unit making it a fire hazard. The bathroom was in disrepair as the toilet paper holder and towel hanger were broken. A hole was observed on the bathroom wall which needed to be patched. The bathroom/shower was dirty and needed to be cleaned.
Room A4 (located in the detached apartment) was missing a smoke detector. The hot water temperature in room A4 was measured at 124.6 degrees F.
The screen door in room A3 (located in the detached apartment) was in disrepair (torn screen). The wall AC unit was not secured and was missing the side pieces, preventing bugs/insects from coming inside the room. The call light system needed to be secured as it was loose from the wall. The hot water temperature in room A3 was measured at 129.8 degrees F.
The window AC unit in room 15 had an opening between the AC unit and the window, making it accessible for bugs/insects to enter the room through the opening.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC809 (FAS) - (06/04)

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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: 08/23/2022

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Applicant understands that all concerns listed on this report will need to be corrected prior to licensure. Once Applicant has made corrections, LPA will return on a future date for a final inspection, ensuring facility is in compliance and ready for licensure.

Due to time constraints, Component III will be conducted on a future date.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC809 (FAS) - (06/04)

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