198603586-5-7-2026-28-AS-DSIS-DTYQRL-20260511122406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 05/07/2026
Date Signed: 05/07/2026 10:14:19 AM

Unsubstantiated

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
12/15/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251215140448

FACILITY NAME:	HENRIETTA'S LEVEN OAKS		FACILITY NUMBER:	198603586
ADMINISTRATOR:	STEPHANY PEREZ		FACILITY TYPE:	740
ADDRESS:	120 S. MYRTLE AVENUE		TELEPHONE:	(213) 478-0800
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	80	CENSUS: 42	DATE:	05/07/2026
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Claudia Sanchez, Administrator		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Staff neglect resulted in resident sustaining a fracture

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent complaint visit in response to the above-mentioned allegation. LPA met with the Administrator, Claudia Sanchez and explained the reason for the visit.

On 12/16/2025, the initial investigation visit was conducted. The investigation consisted of the following:
LPA requested a copy of staff and resident rosters. LPA conducted a tour of facility and common areas with the Assistant Administrator. LPA also requested copies from Resident#1 (R1’s) file such as the Face Sheet, Physician’s Report, Admissions Agreement, and other pertinent documents. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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-20251215140448

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: 05/07/2026

NARRATIVE

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During today's visit the investigation revealed the following: in regard to the allegation, “Staff neglect resulted in resident sustaining a fracture.” It is alleged that on 12/01/2025, R1 fell out of bed and sustained a broken right hip. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Salant. LPA reviewed IB interviews which revealed the following: There is not enough evidence to suggest that the staff members were neglectful or demonstrated lack of care and supervision resulting in R1 falling out of bed. At the time R1 fell out of R1’s bed, there were no specific doctors' orders on file recommending that R1 have a bed with rails or any type of specialized supervision. R1 was known and allowed to ambulate on and off R1’s bed on R1’s own, prior to R1’s fall without assistance. There is not enough sufficient evidence to substantiate.

Based on statements and interviews conducted with staff, residents, review of resident 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.

An exit interview was held and a copy of this report was provided to the Administrator, Claudia Sanchez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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