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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 04/03/2025
Date Signed: 04/03/2025 04:26:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
02/06/2025 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250206090424
FACILITY NAME:HENRIETTA'S LEVEN OAKSFACILITY NUMBER:
198603586
ADMINISTRATOR:STEPHANY PEREZFACILITY TYPE:
740
ADDRESS:120 S. MYRTLE AVENUETELEPHONE:
(213) 478-0800
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 48DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Claudia Sanchez, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff does not ensure facility is in good repair.
Staff does not provide a safe environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted an subsequent unannounced 10-day complaint visit at the facility and met with Claudia Sanchez, Administrator to discuss the purpose for today's visit. The purpose of the visit is to investigate the above allegations.

On 02/07/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA interviewed the Assistant Administrator, Staff #1 (S1) - Staff #4 (S4). LPA also interviewed Resident #1 (R1) – Resident #5 (R5). LPA obtained copies from Resident #1 (R1) to Resident #3 (R3) file such as Physician's Report, Face Sheet, and Special Incident Reports. LPA toured the facility with the Assistant Administrator. LPA also obtained the staff and residents rosters, weekly menu schedule and staff training.

On 02/19/2025, LPA conducted phone interviews with Resident #6 (R6) to Resident #8 (R8).

During today's visit, LPA obtained the following documents: Staff and Client roster.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 28-AS-20250206090424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HENRIETTA'S LEVEN OAKS
FACILITY NUMBER: 198603586
VISIT DATE: 04/03/2025
NARRATIVE
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The investigation revealed the following: in regards to the allegation "Staff does not ensure facility is in good repair.” It is alleged that there are mass problems with plumbing with many bathrooms that don’t work and have sufficient heat for water. The Assistant Administrator, three (3) out of four (4) staff denied the allegation. One (1) out of four (4) staff did not know so did not provide an answer to the allegation. Six (6) out of eight (8) residents denied the allegation. LPA checked 9 residents’ bathrooms hot water measured between 105 to 120 Degrees F which is within Title 22 Regulations. However, water temperature in bathroom #5 was measured at 142.1 Degrees F. This deficiency will be addressed on a separate case management report. LPA observed that all 9 bathrooms observed have working toilets. However, the bathroom in Rm#11 had a showerhead that was not working properly with water pressure was insufficient for a resident to take a shower. The bathroom in Rm#29 also was clean and well-kept but had a very foul odor from an unknown source. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was sufficient supportive evidence to concur with the reported allegation.
Allegation: “Staff does not provide a safe environment for residents.” It is alleged that there were workers peeling the previous stuff on the wall creating a mess and endangering the residents to fall. All staff interviewed denied the allegation. Seven (7) out of eight (8) residents denied the allegation. One (1) out of eight (8) residents stated while moving belongings from one room to another, the resident slipped on a pad that was placed by a staff due to a leak which caused the resident to sustain an injury. LPA also observed during the initial visit dated on 2/7/2025, construction workers working on the 2nd floor and noticed tools such as hammers, mallets, drills, vacuum cleaners, wires, and vinyl flooring tiles in the hallway which are potential trip and fall hazards. LPA confirmed that there are residents living in these areas and residents potentially have access to these items. LPA observed workers working inside of the rooms and there is no staff ensuring that the residents are not grabbing or accessing these items. LPA took pictures of all of these tools during the visit dated 2/7/2025. In addition, there are no posters, warning signs or items giving a residents a heads up of the issues of these items in the hallway. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was sufficient supportive evidence to concur with the reported allegation.

Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 28-AS-20250206090424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HENRIETTA'S LEVEN OAKS
FACILITY NUMBER: 198603586
VISIT DATE: 04/03/2025
NARRATIVE
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Exit interview held with the Administrator, Claudia Sanchez, and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 28-AS-20250206090424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2025
Section Cited
CCR
87307(d)(6)
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(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
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Administrator will ensure to keep indoor passageways clear and free of obstruction and provide a photo of the hallways to the LPA by POC due date.
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Based on observation during the initial visit dated on 2/7/2025, LPA observed construction workers working on the 2nd floor and noticed tools such as hammers, mallets, drills, vacuum cleaners, wires, and vinyl flooring tiles in the hallway which are potential trip and fall hazards which poses an immediate health, safety, or personal rights in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 28-AS-20250206090424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2025
Section Cited
CCR
87303(a)
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(a) 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:
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Administrator will submit a photo of the showerhead working properly and photo of the clean bathroom in rm#29 to the LPA by the POC due date.
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Based on observation, the bathroom in Rm#11 had a showerhead that was not working properly with water pressure was insufficient for a resident to take a shower. The bathroom in Rm#29 also was clean and well-kept but had a very foul odor from an unknown source. This poses a potential health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
02/06/2025 and conducted by Evaluator Daniel Konishi
COMPLAINT CONTROL NUMBER: 28-AS-20250206090424

FACILITY NAME:HENRIETTA'S LEVEN OAKSFACILITY NUMBER:
198603586
ADMINISTRATOR:STEPHANY PEREZFACILITY TYPE:
740
ADDRESS:120 S. MYRTLE AVENUETELEPHONE:
(213) 478-0800
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:80CENSUS: 48DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Claudia Sanchez, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide adequate food service to residents.
Staff do not provide a comfortable temperature for residents.
Staff does not treat residents with dignity and respect.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Daniel Konishi conducted an subsequent unannounced 10-day complaint visit at the facility and met with Claudia Sanchez, Administrator to discuss the purpose for today's visit. The purpose of the visit is to investigate the above allegations.

On 02/07/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA interviewed the Assistant Administrator, Staff #1 (S1) - Staff #4 (S4). LPA also interviewed Resident #1 (R1) – Resident #5 (R5). LPA obtained copies from Resident #1 (R1) to Resident #3 (R3) file such as Physician's Report, Face Sheet, and Special Incident Reports. LPA toured the facility with the Assistant Administrator. LPA also obtained the staff and residents rosters, weekly menu schedule and staff training.

On 02/19/2025, LPA conducted phone interviews with Resident #6 (R6) to Resident #8 (R8).


Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 28-AS-20250206090424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HENRIETTA'S LEVEN OAKS
FACILITY NUMBER: 198603586
VISIT DATE: 04/03/2025
NARRATIVE
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During today's visit, LPA obtained the following documents: Staff and Client roster.

Allegation: “Staff do not provide adequate food service to residents.” It is alleged that there is a lack of food and nourishment in the facility, and if residents request more food, they don't get it. During today’s visit, LPA interviewed the Administrator and all staff denied the allegation. All staff interviewed indicated that all residents at the facility receive three meals and three snacks per day. All staff interviewed also indicated that facility provides a sufficient amount of food to all of the residents in care. LPA interviewed eight (8) out of eight (8) residents all claim they get enough food from the facility staff and are provided food, snack, or drink when they request it. LPA toured the kitchen and dining area. LPA observed that there is an sufficient amount of 2-day perishable and 7-day non-perishable food at the facility. LPA also received and reviewed the weekly meal schedule which indicate well balanced meals. LPA observed residents eating their meal at the dining hall during lunch time from 12:15pm to 12:45pm. LPA observed eating the following items for lunch during the visit: Grilled chicken, white rice, vegetables, and sweet tea or water. Residents were in a pleasant mood while continuing to eat lunch. Assistant Administrator and all staff interviewed also mentioned that residents are provided alternative meal options, snacks, and sandwiches if residents asks for it. LPA observed no concerns regarding residents not getting enough food from the facility. Therefore, there was insufficient evidence to corroborate with the allegations.

Allegation: “Staff do not provide a comfortable temperature for residents.” It is alleged that there is no heat or air conditioner on the whole top floor. All staff interviewed denied the allegation. Six (6) out of eight (8) residents denied the allegation. Two (2) out of eight (8) residents stated that the bedroom was either too hot or too cold. According to the resident interview, one of the residents temporarily moved to the first floor. The other resident has a portable heater which helps manage to keep the bedroom at a warm temperature. During the visit, LPA noticed the facility temperature on the 1st and 2nd floor to be at an appropriate temperature and not at a temperature of concern. Based on staff interview, the Assistant Administrator stated that there have been no current issues with the air conditioner and heater. Assistant Administrator stated that if there were any complaints, the facility maintenance department would be informed and the problem would be resolved. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 28-AS-20250206090424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HENRIETTA'S LEVEN OAKS
FACILITY NUMBER: 198603586
VISIT DATE: 04/03/2025
NARRATIVE
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Allegation: “Staff does not treat residents with dignity and respect.” It is alleged that the staff harassed a resident multiple times. Interviews conducted with the Assistant Administrator and four (4) out of four (4) staff denied the allegations. Eight (8) out of Eight (8) residents interviewed denied the allegations and stated that they are not harassed by the staff and are satisfied with the services they receive at the facility and stated that staff treat them with dignity and respect. No paperwork observed in the files that showed the staff have been reprimanded for mistreating, harassing, or disrespecting staff. LPA also reviewed staff training on Proper Hygiene Practices, Dignity and Privacy date of training 1/16/2025 and Dementia Residents and Resident Rights date of training 4/24/2024. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held with the Administrator, Claudia Sanchez and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8