198603586-1-23-2024-28-AS-DSIS-D26V6Z-20240205151020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 01/23/2024
Date Signed: 01/23/2024 01:40:46 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 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: 40	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Claudia Sanchez - Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff do not ensure residents have adequate night time supervision.

INVESTIGATION FINDINGS:

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

The investigation consisted of the following:
During initial visit dated 1/16/24 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. During todays subsequent visit LPA obtained copies of staff/resident rosters and reviewed video surveillance.

(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: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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: 01/23/2024

NARRATIVE

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The investigation revealed the following:

Allegation: Staff do not ensure residents have adequate night time supervision.
It is alleged that staff have been found sleeping at the desk during the night hours. LPA interviewed 5 staff (2 of which work nights) and 5 out of 5 staff denied the above allegation. 4 out of 5 Staff interviewed stated that they have never fallen asleep during their shift nor have they ever witnessed/heard of another staff sleeping during the night shift. LPA interviewed 5 residents and 4 out of 5 residents denied the above allegation and stated that they have never seen or heard of staff sleeping at night. Interviews with administrator and 2 night staff indicated that there are 3 night staff during each night shift. 5 out of 5 residents stated that they are provided with adequate night time supervision and are assisted if needed in a timely manner at night. LPA reviewed night surveillance footage from dates 12/22/23-12/25/23, 12/29/23-1/2/24 and 1/19/24-1/21/24, there were no signs of staff sleeping at the front desk/TV area or dining area during the night time hours of 6pm-6am.

Based on statements and interviews conducted with staff and residents, and review of surveillance footage, 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 Claudia Sanchez.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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