198603586-8-30-2022-28-AS-JKAN-CHSUJC-20220830153715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:37:21 PM

Document Has Been Signed on 08/30/2022 03:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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: 28	DATE:	08/30/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Staff / Madelene Sasha Sanchez Executive Director / Lupe Harvey		TIME COMPLETED:	02:30 PM

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	Licensing Program Analysts (LPAs) Joe Katrdzhyan, Nune Margaryan and Valeria Maldonado conducted an announced follow up to the pre-licensing inspections conducted on 8/23/22 and 8/26/22. Licensee / Specialized Community Healthcare Company., has submitted an application to operate a Residential Care Facility for the Elderly for a capacity of eighty (80) residents, ages 60 and over. Since the initial pre-licensing inspection conducted on 8/23/22, Licensee has obtained a revised STD 850 / Fire Safety Inspection Request Form. The facility now has an approved fire clearance for forty eight (48) ambulatory residents, twenty five (25) non-ambulatory residents and seven (7) bedridden residents only. According to the STD 850 / Fire Safety Inspection Request Form, All Non-ambulatory residents must reside on the first floor of the facility and ONLY Ambulatory residents shall reside on the second floor. Rooms for bedridden residents = B1, A2, 4, 5, 8, 9 and 12. The new application is being processed as a change of ownership. There are currently twenty eight (28) residents living at the facility. There are two (2) bedridden residents residing at the facility. Henrietta's Leven Oaks has a Dementia Care Program and will be accepting and caring for residents with dementia, upon licensure. The following concerns need correction; 8/30/22, LPA Katrdzhyan s/w Alan at Department of Industrial Relations and expressed the concern of the building not having an operable elevator and was told that they will pull the facility file/notes and have someone call back with an update. Currently waiting on a response from DIR to see if building can operate without an operable elevator or is it required by the State to have the elevator made operable due to building having 2 floors.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/30/2022

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

8/30/22, Per conversation with Greg Boyajian / Building & Safety Manager at City of Monrovia, LPA was told that the permit on the wheelchair lift had been cancelled and the Applicant was asked to have the wheelchair lift removed. The Applicant was given 30 days to remove the wheel chair lift. (the wheel chair lift was installed by the Applicant illegally, prior to obtaining a permit from the city)

LPA's reviewed physician's reports for Residents 1 - 28 and observed the following concerns;

1. Resident #1 (R1) had an incomplete physician's report.
2. Resident #2 (R2) needs an updated physician's report as the one on file is dated 4/23/19.
Resident has a dementia diagnosis.
3. Resident #3 (R3) has an incomplete physician's report.
4. Resident #4 (R4) has contradicting information listed on their physician's report. Physician has
indicated that R4 has an MCI diagnosis. R4 is listed as Ambulatory but needs assistance with
bathing, dressing, grooming, feeding, toileting, handling cash and storing/administering meds.
R4's illness is listed as Alzheimer’s disease.
5. Resident #5 (R5) is missing a physician's report.
6. Resident #6 (R6) has an incomplete physician's report (missing pg 6).
7. Resident #7 (R7) has contradicting information listed on their physician's report. Resident has a
Dementia diagnosis but is listed as Ambulatory.

Per the Applicant, corrections will be made by 9/30/22.
An exit interview was conducted and a copy of this report was issued.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2