198603586-4-22-2024-28-AS-RORN-D4NMD9-20240425093045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 04/22/2024
Date Signed: 04/22/2024 04:15:45 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
04/18/2024 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20240418152247

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:	04/22/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Staff#2, staff in charge		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff mistreated resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with staff#2, staff in charge. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to staff#2 and administrator over the phone.

The investigation consisted of resident interviews, staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster, staff’s training records and residents’ facility files.

The investigation revealed the following. In regards of facility staff mistreated resident, it was alleged staff covered the resident#1 (R1)’s mouth and nose during morning dressing. LPA interviewed residents, four (4) out of five (5) residents interviewed could not corroborate the allegation. One (1) out of five (5) residents corroborated the allegation. Residents interviews revealed staff did not cover resident’s mouth and nose when dressing them. All four (4) staff interviewed denied the allegation. Staff stated R1 had a history of feeling irritated when changing clothes. (-continued in LIC 9099C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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-20240418152247

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: 04/22/2024

NARRATIVE

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Staff stated they were being careful while providing care and dressing residents. Staff had in-service training on providing care the residents. Per LPA’s observation, residents looked happy during the physical plant. Thus, the facility did not mistreat resident while in care.

Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above.

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

An exit interview was conducted with staff#2. The findings were discussed. A copy this report was provided at time of visit.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC9099 (FAS) - (06/04)

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