198603586-4-6-2023-28-AS-LHIS-CU5KWS-20230727081622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 04/06/2023
Date Signed: 04/06/2023 04:11:11 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230313092735

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:	DATE:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	12:27 PM
MET WITH:	Claudia Sanchez, Administrative Assistant		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff do not respond to resident's call button in a timely manner.
Staff do not provide resident with nutritious meals.
Resident's bathroom is in disrepair.
Administrator is not communicating with Ombudsman.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit in reference to the above allegations. LPA explained the purpose of the visit to Administrative Assistant/Med-Tech Claudia Sanchez. Administrator Lupe Harvey was not available during the visit.

The investigation consisted of the following: On 3/20/23 & today a tour of the interior and exterior physical plant was conducted. The physical plant tour focused on bathroom plumbing, hot water temperature, call light system, and kitchen food supply. Staff (S1- S6) and residents (R1 - R7) were interviewed. The following documents pertaining to R1 were reviewed and obtained: Identification and Emergency Information, Physician Report, Physician Order, resident roster, LIC 500 Personnel Report, and Food Menus [regular, special diets, and alternate menu]. NOTE: Documents not provided: Food Handling Certificates, Registered Dietician information (only website was provided), and plumbing report / invoice.

See LIC 9099C for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20230313092735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/06/2023

NARRATIVE

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Allegation: Staff do not respond to resident's call button in a timely manner. It is alleged that staff take over 30 minutes to 2 hours to respond to signal/call light requests made by residents, especially during night hours due to the facility being short staffed. According to staff interviews, the response time varies between 5 to 20 minutes depending on whether the call request is received during meal times. There are a total of 14 staff working at the facility, of which [10] staff are caregivers. There are 3 caregivers during the day shift, four (4) staff between 3 PM- 12 AM, and two (2) caregiver/med-techs during the night shift. Staff stated that resident (R1) did not want to purchase a signal call pendant. The call light system was tested and is operational. It is tested once a month by maintenance staff to ensure there are no faults. Staff indicated that caregivers use walkie-talkies to communicate and each caregiver is assigned specific residents. The Administrative Assistant/med-tech Staff (S1) is not assigned residents, but assists with caregiver responsibilities if other caregivers are busy with other residents. A total of seven (7) residents were interviewed. Four (4) out of seven (7) stated staff take a long time to respond to their calls, and sometimes have to yell for help, especially during night time hours.

Allegation: Staff do not provide resident with nutritious meals. It is alleged that resident (R1's) nutritional health needs are not being met because the resident is often provided cup o noodles, sandwiches, or rice with soy sauce to meet it's vegetarian diet. Resident (R1's) has multiple medical diagnosis that require a special diet, and also has religious dietary restrictions. Staff interviews indicated that the facility offers regular food, an alternative menu, diabetic and low sodium diet food, but it does not have a separate vegetarian menu or low carbohydrate menu that meets R1's needs. Staff stated that the resident is accommodated and given rice, vegetables, noodles, or cultural TV dinners are purchased. Staff staff stated that R1's MD has been notified that family sends the resident unhealthy drinks and candy. In addition, staff reported that resident primarily requests quesadillas and pancakes, skips lunch meals, and does not adhere to it's physician ordered diabetic diet. Four (4) out of seven (7) residents interviewed stated they are not receiving nutritious meals i.e. very little vegetables and fruit, and at least twice a week they are served hot dogs or pizza. Based on resident (R1's) file documents i.e Physician's Reports and appraisals R1 requires a renal, diabetic, low salt, low carbohydrate diet, pureed diet, and vegetarian diet. The facility is not ensuring the resident obtains required food items to meet it's multiple medical diagnosis. Resident (R1) requires a renal diet and it is not on a facility renal diet. Additionally, on 3/20/2023 Administrator was unable to provide LPA kitchen staff food handling certificates, and the main cook's certificate was expired. Corporate staff (S4) stated that the facility has a Registered Dietician (RD) that evaluates food menus once a year. However, staff (S4) did not provide RD's contact information and could not recall whether R1's special dietary needs were evaluated by the Registered Dietician. The facility did not provide proof that an RD is contracted. Only a link to a general website "TELADOC" was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20230313092735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/06/2023

NARRATIVE

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Allegation: Resident's bathroom is in disrepair. It is alleged that resident (R1's) bathtub/shower plumbing has had an intense leakage that needs repair for approximately 3 - 4 months. Staff were made aware and instructed R1 not to use it's room bathtub/shower and instructed both residents that share the bathroom to go downstairs to the 1st floor to bathe. Resident (R1) is ambulatory but often uses a wheelchair which has caused the resident a major inconvenience every time it bathes. A total of seven (7) residents were interviewed, of which five (5) residents confirmed that there have been plumbing issued, like no hot water in their bathrooms for a long time, since 2022. Staff acknowledged that rooms 28 and 29 have major plumbing issues since January 2023. The facility contacted the City of Monrovia so that they can shut off the water for repairs, but the project was postponed. No issues with water for cooking and other needs were reported. However, residents (R1 & R2) were no relocated to other vacant rooms in the facility, and as of today the plumbing problem has not been repaired in 2 rooms (B1 & B2) located outside the main building. The hot water had very low water temperature readings. Rooms 28 & 29 plumbing issues have been repaired.

Allegation: Administrator is not communicating with Ombudsman. It is alleged that the Ombudsman has made multiple attempts to communicate with facility Administrator regarding resident concerns, but did not receive a return phone call or reply to emails sent. On 1/27/2023, 2/1/2023, 2/7/2023, 2/17/2023 (in person & via telephone call), and on 2/24/2023 (via email) attempts were made to communicate with facility Administrator. As of 3/10/2023, the Ombudsman had not received a response from the facility regarding the 2 facility visits, 2 telephone messages, and 1 email.

Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D.

Exit interview was conducted with Administrative Assistant Claudia Sanchez. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20230313092735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 04/14/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...	1 2 3 4 5 6 7	Licensee shall: 1. Develop a plan to ensure staffing is compentent and staff receive continuous training in care responsibilities. 2. Conduct staff training Submit proof by POC due date.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on interviews conducted, staff take a long time to respond to resident calls; which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
Request Denied Type B 04/14/2023 Section Cited CCR 87555(b)(7)	1 2 3 4 5 6 7	General Food Service Requirements. The following food service requirements shall apply:Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Licensee shall: 1.Consult with a Registered Dietician to formulate special diet foods for R1 2. Submit proof that kitchen staff have food handling certificates 3. Submit a written plan of how the deficiency was corrected.
	8 9 10 11 12 13 14	Based on record review and interviews conducted, the facility fails to provide R1 physician ordered special diet and a cultural/religious diet that meets dietary standards and physician order; which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230313092735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 04/14/2023 Section Cited CCR 87303(e)(6)	1 2 3 4 5 6 7	Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.	1 2 3 4 5 6 7	Licensee shall provide: 1. A written plan of how the deficiency was corrected. 2. Copy of Plumbing Invoice Report **If an extension is needed submit a POC extension request by POC due date.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on interviews conducted and physical plant observation rooms 28-29, and B1- & B2 have hot water issues and/or plumbing leaks; which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type B 04/14/2023 Section Cited CCR 87468.1(a)(9)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have communications to the licensee from their representatives answered promptly and appropriately.	1 2 3 4 5 6 7	Licensee shall submit a written plan of correction, and proof that the Ombudsman has been contacted.
	8 9 10 11 12 13 14	Based on record review, facility Administrator failed to respond to R1's Ombudsman representative in a timely manner. Ombudsman made two (2) facility visits, 2 telephone messages, and sent 1 email and did not receive a response; which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

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