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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:16:53 PM

Document Has Been Signed on 10/05/2023 12:16 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 OAKSFACILITY NUMBER:
198603586
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:120 S. MYRTLE AVENUETELEPHONE:
(213) 478-0460
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 80CENSUS: 33DATE:
10/05/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Interm-Administrator Claudia SanchezTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Ashley Calderon, made a unannounced annual continuation case management visit. LPA met with interm-Administrator Claudia Sanchez and discussed the purpose of today's visit. The facility is licensed to serve: Elderly residents ages 60 and over. Approved for (48) ambulatory residents and (32) non-ambulatory residents. (7) non-ambulatory can be bedridden. Bedroom # B1,A2,4,5,8,9,12 are cleared for bedridden residents.

During today's visit LPA Calderon did a total of (5) resident files. LPA reviewed files and did not observe any deficiencies in resident files and all residents had appropriate documentation's, physician reports and TB.

LPA completed CARE inspection tool to complete annual required inspection.

No deficiencies noted under California Title 22. An exit interview was conducted and a copy of this report was provided to Interm-Administrator Claudia Sanchez.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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