198603586-10-9-2023-28-AS-EIRA-CM3VQY-20221213153907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 12/13/2022
Date Signed: 10/09/2023 11:24:05 AM

Document Has Been Signed on 10/09/2023 11:24 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
GREATER LA AC/SC, 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: 31	DATE:	12/13/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Claudia Sanchez- Assistant Administrator and Lupe Harvey-Facility Administrator.		TIME COMPLETED:	04:00 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) Elizabeth Irra and Glenn Trueman conducted a post licensing visit. LPAs met with Claudia Sanchez (Assistant Administrator) and Lupe Harvey (Facility Administrator) and explained the purpose of today's visit. During this visit, LPAs conducted a facility tour and reviewed files for Staff #1 (S-1) through Staff #6 (S-6). LPAs also reviewed Resident files for Resident #1 (R-1) through Resident #6 (R-6). 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 living room/television room, reception/office area, kitchen, dining room, conference room, laundry room and resident rooms. The second floor of the main building consists of resident rooms. The facility is approved for (48) ambulatory, (32) non-ambulatory of which (7) may be bedridden (rooms assigned for bedridden are B-1, A-2, A-4, A-5, A-8, A-9 and A-12). This facility has an approved hospice waiver for (15). There is (1) bedridden resident and there are (7) under hospice care. 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. Bathrooms are clean and operational with non-skid mats. Appropriate food supply of two days of perishables and seven (7) days of non-perishables. Refer to LIC 809C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HENRIETTA'S LEVEN OAKS	FACILITY NUMBER: 198603586
	VISIT DATE: 12/13/2022

NARRATIVE

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Resident and staff records are centrally stored and locked in the Executive Director's office.
Each resident room is equipped with a smoke detector.
Carbon monoxide detectors were observed.
Fire extinguishers were fully charged and last serviced on 06/02/2022.
Functioning telephone on the premises.
Hot water temperature was tested throughout the facility. Water temperatures: room #1 measured at 119.8*, room #4 measured at 119.4*, room #6 measured at 112.2*, room #7 measured at 107.9*, room #11 measured at 113.1*, room #30 measured at 113.5*, room #32 measured at 105.2*, room #27 measured at 114.6*
Toxins such as cleaning solutions and detergent soap and sharps are also locked in the storage room.
Emergency Disaster Plan, Personal Rights and Facility Sketch were observed posted.

Exit interview, appeal rights and a copy of this report was provided to Lupe Harvey-Facility Administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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