198603586-1-19-2023-28-AS-RORN-CP4NWE-20230216094924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603586
Report Date: 01/19/2023
Date Signed: 01/19/2023 11:43:45 AM

Substantiated

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
01/10/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230110110037

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: 27	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Assistant Administrator Claudia Sanchez		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff did not adequately supervise resident resulting in resident wandering off on more than one occasion.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Assistant Administrator Claudia Sanchez and explained the reason for the visit.
The purpose of the visit is to investigate the above allegation.
At today's visit Resident and Staff Roster was submitted.
R 1's file was reviewed.
At 9:40 A.M. Assistant Administrator was interviewed.
At 10:00 A.M. tour of facility was conducted with LPA and Assistant Administrator which included 1st floor front door, R1 Room 11, rear of facility exit, and 2nd floor exit doors. All signal systems were operable.
At 10:15 A.M. Staff S 1 was interviewed.
At 10:30 A.M. Staff S 2 was interviewed.
At 10:50 A.M. interview was conducted telephonically with Administrator Lupe Harvey.
In regards to the allegation Facility staff did not adequately supervise resident resulting in resident wandering
off on more than one occasion, based on file review, and interviews conducted it was revealed by staff

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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-20230110110037

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: 01/19/2023

NARRATIVE

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that R 1 on at least 2 occasions left the facility unassisted.
On 1 occasion Monrovia Police department escorted R1 back to the facility.
Staff stated that R 1 had gone alone to Bank of America and restaurant in shopping plaza across the street.
Administrator stated that Police had found R 1 around 2 A.M. walking in the direction of the police station outside of the facility a block away.
File review revealed that a Pre- Placement Appraisal was done on 02/22/2022 which revealed in Health History R 1 hospitalized due to wandering.
Appraisal Needs and Services dated 03/04/2022 listed in Background Information that R1 was found a few times wandering around by police who would always take him back home.
Listed under Method of Evaluating Progress states monitor closely.
Physician's Report dated 02/22/.2022 listed under Mental Condition is checked yes for confused/disoriented and no for able to leave facility unassisted.

Based on review of documents and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 1. See LIC 9099D.

It should be noted that R1 has relocated to another assisted living.

Exit interview conducted and copies provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230110110037

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/26/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	Care of Persons with Dementia Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: there is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to send a plan to licensing regarding how staff will ensure that residents with dementia who are not allowed to go out of the facility unassisted are being provided with adequate supervision. Plan to be sent to Licensing by POC due date (01/26/23)
	8 9 10 11 12 13 14	Based on file review and interviews Licensee failed to support residents safety and health care needs with R 1 leaving the facility on multiple occasions which presented a Potential Risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

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