198603586-7-11-2024-28-AS-NGAA-D742KN-20240711172814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 07/11/2024
Date Signed: 07/11/2024 05:28:24 PM

Document Has Been Signed on 07/11/2024 05:28 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: 38	DATE:	07/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Claudia Sanchez, Designee Administrator		TIME COMPLETED:	05:30 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 Analyst (LPA) Galarza and Research Data Analyst Michael Moriel conducted an unannounced annual inspection visit. The purpose of the visit was explained to Designee Administrator Claudia Sanchez. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place. It consists of 48 resident rooms in a 2 story main building and 2 detached buildings, 1 activity rooms, dining room, laundry area, 2 courtyard patio areas, and one 2nd floor balcony.

The following were observed/inspected:

Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: A hospice waiver for 15 residents has been approved. A fire clearance for 48 ambulatory, 32 non-ambulatory, of which 7 may be bedridden is in place. Facility handles resident P & I monies for a total of 10 residents. However, the licensee does not have a Surety Bond. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 8/26/2024.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. The last fire drill was conducted on 6/17/2024. The facility has fully charged fire extinguishers. The signal system was tested and is operational. Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. Water temperature readings measured between 92.8 DF - 136.9 DF. Stairwell evacuation chairs were observed.

*Note: Blue tarps were observed on the roof. Elevator is not operable at this time.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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 5

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: 07/11/2024

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

Staffing: A total of 15 staff members provide care and supervision to the clients. Administrator Stephany Perez is a corporate office staff. Designee Administrator Claudia Sanchez is in charge of daily on-site operations.

Personnel Records/Staff Training: Administrator certificate is current. Staff have criminal background clearance and training. Six (6) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed.

Resident Records/Incident Reports: A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and medication records. RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.11 residents are on modified diets. Physician orders are on file and special diet lists are kept in the kitchen area. The freezer door thermometer is not operable, but 2 portable thermometers were observed inside.

Incident Medical and Dental: Six (6) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by Access or insurance transportation services. Facility has one (1) van for resident transport, but is presently not working.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chairs are in place. The elevator is inoperable. All non-ambulatory residents are on the 1st floor. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: Four (4) residents are receiving hospice services and one (1) resident receives home health services. Nine (9) residents have a Dementia diagnosis and are located in the 1st floor. Postural support physician orders are on file. Full bed rails for mobility assistance were observed in some resident rooms. No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Claudia Sanchez A copy of the report and appeal rights was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 07/11/2024 05:28 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

FIRE SAFETY All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that a total of 5 out of 20 resident rooms inspected did not have smoke detectors with batteries, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure all resident room smoke detectors are operational. Provide a written plan of correction by tomorrow that states how the deficiency was corrected. *Note: Maintenance staff was observed replacing batteries during the visit.

Type A

Section Cited

CCR

87303€(2)

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that hot water temperature readings in resident rooms ranged between 92.8 DF - 136.9, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Submit a water temperature log of all resident rooms. Readings must be within 105-120DF.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/11/2024 05:28 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87216(a)

Bonding

(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above because P & I monies are handled and there is no Surety Bond in place, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Licensee shall obtain a Surety Bond and submit proof by POC due date.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, licensee did not comply with the section cited above in that 11 discarded mattresses and 2 nightstands were observed in the parking lot area, as well as 1 electrical outlet near the laundry area and in the conference room did not have a covering, and rm B1 had a broken toilet, which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Submit picture proof evidence that all the discarded furniture has been removed, electrical outlets have coverings, and plan to fix room B1's toilet.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/11/2024 05:28 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(C)

Personal Accommodations and Services

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the majority of all resident beds that were inspected did not have mattress pads, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Administrator shall submit a purchase order receipt and pictures of mattress pads on resident beds.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5