198603586-12-8-2022-28-AS-RORN-CN6R29-20230117113759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 12/08/2022
Date Signed: 12/08/2022 01:25:48 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
12/01/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221201120217

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: 31	DATE:	12/08/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lupe Harvey		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident is being unlawfully evicted while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Lupe Harvey and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Lupe Harvey, and Resident 1 (R1). LPA obtained copies of Staff and Resident Rosters. LPA conducted a telephone interview with Department of Health Services/ Housing for Health (DHS HFH) Case Worker Carmen Zavala. LPA reviewed R1-2's facility file and collected copies of the following documents: R1-2's Physician's Report for Residential Care Facilities for the Elderly (RCFE), R1-2 Preplacement Appraisal Infromation and R2 Eviction Notice dated 11/23/22.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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-20221201120217

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: 12/08/2022

NARRATIVE

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Investigation revealed the following: Regarding allegations, Resident is being unlawfully evicted while in care, it is alleged that a facility resident is being put out/ evicted from the facility on 12/1/22 and does not have anywhere to go. Interview conducted with Administrator Lupe Harvey revealed that at the moment the facility has only issued a notice of eviction to R2. Administrator stated that there is no other resident being evicted from the facility. She stated that R1 is not being evicted and stated that R1 just recently moved in on 11/18/21. She stated that R1 has expressed that they want to move and that she notified DHS HFH Case Worker Carmen Zavala. LPA interviewed DHS HFH Case Worker Carmen Zavala who stated that she is aware that R1 wants to move. She stated that R1 recently moved into the facility on 11/18/22. She stated that at the moment there is no other available housing and R1 is aware. She stated that R1 does have the choice of living independently or with family and has been instructed to reach out to family. Ms. Zavala stated that R1 has been evicted from other facilities and that R1 is noncompliant with their medical care. Interview conducted with R1 revealed that they never stated that they were being evicted. R1 stated that they want to move to another facility and that they need the facility administrator to assist them in finding another facility. R1 stated that they will also follow up with their Department of Health Services Case Worker and that Case Worker is aware that they want to move. LPA reviewed R1's facility file and there was no eviction notice on file. LPA reviewed R2's facility file and did see that R2 was issued an eviction notice on 11/23/22. LPA also reviewed R1-2's Admission Agreements which state Eviction Procedures and both documents were signed by R1-2. Based on LPA review of documents and statements gathered from interviews conducted 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. A copy of the report was provided to Administrator Lupe Harvey

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC9099 (FAS) - (06/04)

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