198603586-10-17-2023-28-AS-RORN-CYAULB-20231207144027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:03:59 PM

Unsubstantiated

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
10/12/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231012115138

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: 37	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Iterm-Administrator Claudia Sanchez		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's property.
Facility staff did not dispense medications as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon made an unannounced visit to conduct a complaint investigation visit. LPA met with Iterm-Administrator Claudia Sanchez and explained the purpose of the visit.

Investigation consisted of: LPA toured residents rooms #3, #9, #15 and #27. Resident #1 (R1) room was observed. LPA collected resident and staff roster. R1's Identification and Emergency Information, Physician Report, Inventory List, Admission Agreement Page Regarding Theft and loss/ Safeguarding Residents property, Preplacement Appraisal, Resident Appraisal . Inventory List for Residents #2-5 (R2-R5). LPA interview Iterm Administrator Claudia Sanchez and Staff #1 - #3 (S1-S3). LPA interviewed Resident #1-#3 (R1-R3) and Resident #5 (R5), LPA checked medications and Centrally Stored Medication Log for Resident #1 - #4 (R1-R4). LPA interview R1's Former Case Manager from Brilliant Corners / DHS.

Continuation on 9099-C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231012115138

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: 10/17/2023

NARRATIVE

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Allegation: Facility staff did not dispense medications as prescribed. Based on today's investigation LPA conducted interviews with staff, Iterm-Administrator and S1-S3 denied the above allegation and informed LPA that all residents get medication as prescribed and mediations are dispensed to residents and all medications are stored in the medication room. Iterm-Administrator and S1-S3 informed LPA that R1 gets medications as prescribed and medications are stored in the medication room. LPA conducted interviews with residents, interviewed revealed 4 out of 4 residents informed LPA that facility is providing and dispensing medications as prescribed.LPA reviewed 4 medications files and all medications are accounted for and administered according to doctor's orders. Interview with R1 revealed having no issued with medications and R1 is assisted with all prescribed medications. Interview with Former Case Manager of R1 stated facility is dispensing medication as prescribed.

Allegation: Facility staff did not safeguard resident's property.
Based on today's investigation LPA conducted interviews with staff, Iterm-Administrator and S1-S3 denied the above allegation and informed LPA staff are not stealing or taking things out of residents rooms and are keeping resident's property safeguarded. Staff interviews with 3 out of 4 staff revealed R1 gives personal belongings to other residents and staff are safeguarding belongings. Interviews with 4 out of 4 staff revealed staff enter residents rooms when staff need to assist residents in room cleaning, routine checks ,and /or need items like clothing to assist with residents needs and staff ensure residents property are safeguarded and residents are aware. Interviews with residents 4 out of 4 stated their belongings are safeguarded in their rooms and denied the above allegation. R1 during interview informed LPA facility staff safeguard their personal belongings and nothing it taken from R1's room and has no issues with staff not safeguarding R1's belongings, R1 admitted to giving away personal items like water. LPA reviewed R1- R5 Inventory of property and all residents refused / opted out in having items listed. Interview with Former Case Manager of R1 informed LPA that R1 is known to give personal items away to other residents and Case Manager informed LPA facility residents are able to have keys to their rooms to safeguard residents belongings and facility has cameras to assist with safeguarding property issues that can arise when living in a board and care.

Based on interviews and record reviews there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Med-Tech Madelene Sanchez and a copy of this report will be sent via email to Interm-Administrator Claudia Sanchez

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

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