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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:26:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/12/2023 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230112084458
FACILITY NAME:HENRIETTA'S LEVEN OAKSFACILITY NUMBER:
198603586
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:120 S. MYRTLE AVENUETELEPHONE:
(213) 478-0460
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 40DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Claudia SanchezTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff does not ensure that residents have hot water.
Facility is in disrepair.
Facility staff does not meet resident's dietary needs.
Facility staff does not maintain resident's room clean and free of trash.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to deliver complaint investigation findings. LPA met with Assistant Administrator Claudia Sanchez and explained the purpose for the visit.

The investigation consisted of: On 01/19/23, LPA Gonzalez conducted interviews with Assistant Administrator Claudia Sanchez, and R1. LPA collected copies of Staff and Resident Rosters, Facility Menu for Week 1/15/23 - 1/21/23, Diabetic Menu Options and a list of diabetic residents. LPA conducted a tour of entire facility inside and out. The tour included observations of facility kitchen, food supply and resident rooms. The following resident rooms were toured/ inspected, and water temperature was measured in each room: # 12, #6, #32, and #24. On 11/27/23, LPA requested and received copies of Staff and Resident Rosters, interviewed Staff 1-4 (S1-4) and R2-5. LPA also conducted a tour of the facility which included observations

(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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 4
Control Number 28-AS-20230112084458
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/27/2023
NARRATIVE
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of the kitchen, food supply, observation of facility elevator and a random selection of resident rooms. LPA measured the water temperature in the resident rooms. LPA additionally reviewed R1’s facility file and collected copies of documents pertinent to the investigation and conducted a phone call to Silverado Hospice.

Investigation revealed the following: Regarding allegation, Facility staff does not ensure that residents have hot water, it is alleged that the facility does not have hot water as of 01/11/23 and resident(s) only received a sponge bath as there was no hot water in the building. Facility also allegedly did not notify resident’s family or responsible parties of the issue with the water. It is also alleged that resident(s) are retaliated against if they speak up when things are not right in the facility. Interviews conducted with facility administrator and staff revealed that the facility does have hot water at all times. Administrator stated that water is checked weekly to ensure that the water is always set at the required temperature that is between 105 F - 120F and stated that family members and responsible parties are notified of any important issues or problems, if any, when they arise. Staff interviewed denied that residents are retaliated against if they bring up any concerns. Interviews conducted with 5 out of 5 residents revealed that the facility always has hot water. 1 out of 5 residents stated that when it is cold the water takes longer to heat up and it might be due to where their room is located which is in the rear of the facility. 5 out of 5 residents denied that staff retaliate against residents if they bring up any concerns. On 01/19/23 and 11/27/23, LPA measured the water temperature in a total of six (6) resident bathrooms and the reading for all bathrooms ranged between 110F - 115F which is between Title 22 regulation requirement. Based on interviews conducted with facility staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

For allegation, Facility is in disrepair, it is alleged that there is no alarm in the rear exit of the facility and there should be one as the facility provides services to residents with dementia, and the facility does not have a working elevator for the residents that live upstairs. Interviews conducted with Administrator Harvey and Assistant Administrator Claudia Sanchez revealed that the facility has 1 nonoperational elevator. They stated that the facility was licensed like that, and the facility was cleared by the Monrovia City Fire Department as well as Department of Industrial Relations (DIR). LPA Gonzalez reviewed approved STD 850 Facility Fire Inspection Request which was approved on 08/25/22 and indicates that all nonambulatory residents are to reside on the 1st floor and all ambulatory residents are to reside on the 2nd floor. This information is reflected on the facility license. On 11/10/22, LPA Katrdzhyan spoke to DIR Senior Inspector who informed LPA Katrdzhyan that DIR does not require the building to have an operable elevator. Senior Inspector also stated
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230112084458
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/27/2023
NARRATIVE
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that the facility elevator is recorded as dormant, and the power record has been landed which means that the elevator is inoperable. DIR will not visit the facility unless the facility decides to make the elevator operable again. Administrator and facility staff stated that the alarm in the rear exit of the facility does work. 4 out of 5 residents interviewed confirmed that the alarm in the rear exit door does work. 1 resident stated that the alarm is located right next to their room and they hear the alarm go off at times. 1 resident was not able to answer the question. LPA observed that the alarm in the rear exit door of the facility was operating properly during the visits that were conducted on both 01/19/23 and 11/27/23. LPA observed that nonambulatory residents are located in the first floor and did not observe any nonambulatory residents on the second floor during the visits conducted on 01/19/23 and 11/27/23. Based on interviews conducted with facility staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff does not meet resident's dietary needs, it is alleged that the facility has not been able to meet a resident(s) special dietary need such as a diabetic diet as it was stated on the resident(s) admission agreement and it is also alleged that resident(s) are supposed to get 3 meals a day and the facility has not met food needs. LPA observed the food supply on 01/19/23 and 11/27/23 and observed residents having lunch. LPA observed that the facility had an ample supply of a variety of fresh fruits, vegetables, proteins, and carbohydrates. LPA also observed facility's food storage and observed sufficient food for 2 days worth of perishables and 7 days worth of non-perishables, which consisted of different meats, vegetables and fruits, breads, dairy, cereals, and variety of canned foods. Interviews conducted with 3 out of 5 residents stated that they follow a special diet and the facility does provide them with alternate meals. 1 resident did not want to continue their interview, 1 resident stated that the food could be tastier but is overall satisfied with the food service. 5 out of 5 residents stated the food that is served is healthy and well balanced and they are served three meals a day which consist of a variety of foods. Interviews with Administrator and staff revealed if any resident follows a special diet they are provided with modified diets. LPA reviewed the food menu and toured the kitchen and observed a healthy selection of foods. LPA reviewed 5 resident's Physician's Reports and 3 reports did not indicate that the residents require a special diet. 2 Physician's Reports did indicate that the resident requires a special diet, and these reports belong to the residents that stated that the facility follows their diet. R1 is no longer a resident of the facility. Based on LPA observations, LPA review of facility menus, and statements gathered from interviews conducted with staff and residents there was not enough supportive evidence to concur with the reported allegation.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230112084458
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/27/2023
NARRATIVE
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For allegation, Facility staff does not maintain resident's room clean and free of trash, it is alleged that resident(s) room is always dirty and on 01/12/23 trash that had been observed the previous week was observed again under a resident(s) bed even after the housekeeper had just vacuumed the room. It is also alleged that the blinds in the resident(s) room are also broken and that they had allegedly been previously broken by staff when they were changing the resident(s). On 01/19/23 and 11/27/23, LPA toured the facility and did not observe that the facility or any residents' room were dirty and did not observe any trash under beds or any broken blinds. There are trash cans placed around the property for residents to use to throw their trash in. The dining tables and floors are wiped and clean. There are no obstructions to the passageways. LPA did not smell any urine nor unpleasant odor around the facility. Administrator and staff stated that the facility is cleaned on a daily basis and as needed and also stated that staff do not break any blinds when assisting residents. Staff stated that if a resident breaks the blinds in their rooms the blinds will be replaced by maintenance staff. 4 of 5 residents interviewed stated that the facility staff clean their rooms daily. 1 resident stated that their room is cleaned regularly but their daughter is the one that does not like certain things. LPA Gonzalez conducted a tour of the entire facility including 6 resident rooms including bathrooms, dining room, kitchen, TV room, outside common area, and backyard and observed the facility to be clean. LPA observed 1 staff cleaning resident rooms/restrooms. Based on interviews conducted with facility staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

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 held. A copy of the report was provided to Assistant Administrator Claudia Sanchez.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4