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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:31:32 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
01/09/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240109123456
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: 37DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Madelene "Sasha" Sanchez - MedTechTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not ensure resident rooms are kept clean.
Staff do not have appropriate training.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Madelene "Sasha" Sanchez - MedTech and explained the reason for the visit.

The investigation consisted of the following:

LPA obtained copies of staff/resident rosters, copy of In-Service Medication Administration Training, reviewed 6 staff files, conducted interviews with 6 staff and 5 residents and toured facility including 8 resident bedrooms.


(Continued on 9099-C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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-20240109123456
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: 01/16/2024
NARRATIVE
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The investigation revealed the following:

Allegation: Staff do not ensure resident rooms are kept clean.

It is alleged that staff do not clean, take out trash or make beds for residents. LPA toured facility a total of 8 resident rooms were checked, beds in each room were observed to be made and rooms appeared to be clean and trash was emptied. LPA interviewed 6 staff and 5 out of 6 staff stated that rooms are maintained daily, trash is thrown out and beds are made, with a deep cleaning that includes mopping, scrubbing and dusting 2 times a week or as needed. LPA interviewed 5 residents and 5 out of 5 residents denied the above allegation and stated their rooms are cleaned daily, deep cleaning is done 2-3 times a week and trash is emptied daily.

Allegation: Staff do not have appropriate training.

It is alleged that the cook and/or janitor are assisting with medication administration and do not have proper training to do so. LPA reviewed 4 staff files that assist with medication and each file had the required medication administration training was documented in their personnel files. LPA interviewed 6 staff and 2 of 6 staff stated they administer medication and are trained, LPA reviewed their files and training was documented. LPA interviewed 5 residents and 5 out of 5 residents stated that the staff that administers medication is the same staff daily and have never been given medicine by a cook/janitor.(LPA reviewed files of staff mentioned, each had proper training documented)

Based on statements and interviews conducted with staff and residents, review of staff files and in-service training records, 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 held, and a copy of this report was provided to Sasha Sanchez.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
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