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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:42:43 PM


Document Has Been Signed on 01/09/2024 03:42 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



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: 38DATE:
01/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Claudia Sanchez - AdministratorTIME COMPLETED:
03:52 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted a case management visit as a result of a deficiency observed during a complaint investigation, under complaint control # 28-AS-20240103165532. LPA met with Administrator Claudia Sanchez.

During complaint investigation it was revealed that facility did not submit a special incident report on an incident that occurred on 1/2/24 to licensing. The incident was an altercation between R1 and R2 where R2 threw food and coffee on R1 and resulted in authorities being called and police report being taken (no injuries were reported).

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on 809D.

Exit interview held and a copy of the report along with appeal rights were provided to Administrator Claudia Sanchez.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/09/2024 03:42 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2024
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements - (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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Administrator to review Reporting Requirements as specified in Title 22 Regulations and complete the LIC9098 stating that they are knowledgeable in all reporting requirements once reviewed and submit completed LIC9098 to LPA via email by POC due date.
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During complaint investigation it was revealed that facility did no submit a Special Incident Report to Licensing as Administrator stated they were waiting for instructions from DHS on how to proceed.
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Administrator to practice reporting requirements moving forward and submit a speical incident report to licensing pertaining this insident via fax.

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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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