198603586-1-9-2024-28-AS-RORN-D22QQY-20240201112305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:41:29 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
01/03/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240103165532

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: 38	DATE:	01/09/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Claudia Sanchez - Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not prevent a resident from being harmed by another resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Claudia Sanchez and explained the reason for the visit.

The investigation consisted of the following:

LPA obtained copies of staff/resident rosters, Physician Reports for both R1 and R2, Incident Report for Altercation between both parties, Police Information and Report Number. LPA interviewed 5 Staff and 5 Residents, and toured dining during lunch hour.

(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20240103165532

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: 01/09/2024

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
26
27
28
29
30
31
32

The investigation revealed the following:
Allegation:
Facility staff did not prevent a resident from being harmed by another resident in care.
It is alleged that on 1/2/24 R1 and R2 had an altercation in which staff not prevent. R2 had allegedly spilled coffee on R1. LPA interviewed staff and 5 out of 5 staff denied the above allegation and stated that when there is an altercation they intervene and separate residents, allow time for them to calm down and then management will speak to each resident individually to provide the best care that is needed, if any. 5 out of 5 staff stated that they are aware that R1 and R2 have a history and try their best efforts to keep them separate and keep a close eye on them when they are within the same area. Interview with S1, staff stated that they have offered residents to switch rooms as they both reside on the same floor and to prevent residents from passing by one another a switch of room has been offered, however, neither resident want to switch rooms. S1 further stated that R1 and R2 have had exchange of words in the past but it had never turned physical until now, authorities were called, a police report was taken, and there have not been any further incidents since. LPA interviewed 5 residents and 5 out of 5 residents state they feel staff responds as quick as possible when there is an argument or altercation, although, at times it happens too fast for staff to arrive right away they feel staff does their best with response time. Interview with R1, resident stated they do not want to switch rooms, Interview with R2 stated the same, both parties stated that there were no injuries during altercation. R1 & R2 stated that they avoid each other and keep distance between one another and know that this is the best way to avoid future altercations. Both R1 and R2 stated that since this last incident no other incidents have happened and are hopeful that no further incidents will occur as they are staying distant from one another.

Based on statements and interviews conducted with staff and residents, review of resident files and incident report, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Administrator Claudia Sanchez.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 2