198603586-12-21-2023-28-AS-RORN-D22MG2-20240201083510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 12/21/2023
Date Signed: 12/21/2023 01:55:58 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
12/14/2023 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20231214115437

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:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Claudia Sanchez-Interim Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff did not safeguard resident's property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan 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 requested staff/resident rosters. Interviewed Staff #1- #4
(S1-S4) and Residents #1 - #4(R#1 - R#4). LPA also toured R1's room and reviewed R1's file. LPA requested a copy of physician's report, identification and emergency information sheet, admission agreement for R1.

The investigation revealed the following: Regarding allegation: Facility staff did not safeguard resident's property:It is alleged that R1’s Agave sweetener was missing from the closet where the sweetener was stored and the lock on the cabinet was not locking.

Cont. 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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-20231214115437

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: 12/21/2023

NARRATIVE

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During LPA's interview with R1, R1 stated that they really cannot remember when and how the sweetener is missing and indicated that the cabinet lock is working in their room now. Staff fixed already and showed the LPA the key for the lock. LPA toured the R1's room with S1 assistance and observed that lock for the cabinet where R1 is keeping their food / cleaning supplies is working. At the time of tour R1 was present in the room. During interviews with residents, 3 out of 4 residents stated to not have lost or missing items from their rooms. They stated sometimes they misplaced items and staff help to look and find them. They did not hear that someone complains about missing items. Interviewed staff stated residents usually misplaced items and staff looks and will find items in residents' rooms. Interviewed staff indicated that R1 is often giving items away and after complaints about missing items. Items like water, juice, nuts R1 offer to residents and to staff. Staff stated that they never take any items from R1 or from other residents. They kindly decline the offers. Staff stated that they respect the residents, they do not go inside the resident's room without permission and do not touch their items.

Based on the observation and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the 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 was conducted and a copy of this report was provided to Claudia Sanchez.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

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