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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603586
Report Date: 06/15/2026
Date Signed: 06/15/2026 03:43:07 PM

Document Has Been Signed on 06/15/2026 03:43 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HENRIETTA'S LEVEN OAKSFACILITY NUMBER:
198603586
ADMINISTRATOR/
DIRECTOR:		STEPHANY PEREZFACILITY TYPE:
740
ADDRESS:120 S. MYRTLE AVENUETELEPHONE:
(213) 478-0800
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 80CENSUS: 40DATE:
06/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:27 AM
MET WITH:Claudia Sanchez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced annual inspection visit. LPA met with the Administrator, Claudia Sanchez and the purpose of the visit was explained. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an updated Infection Control Plan in place.

Operational Requirements: A hospice waiver for 15 residents has been approved. A fire clearance for 48 ambulatory, 32 non-ambulatory, of which 7 may be bedridden is in place. A hospice and Dementia waiver is in place. LPA observed the valid Surety Bond in place. LPA observed the Valid Liability Insurance in place. Fire and disaster drills were last conducted on 04/22/2026.

Physical Plant/Environment Safety: The facility consists of 48 resident rooms in a two-story main building and two (2) detached buildings, activity room, dining room, laundry area, two (2) courtyard patio areas, and one 2nd floor balcony. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. The fireplace is closed and inaccessible to residents. The facility has fully charged fire extinguishers that were last inspected on 11/14/2025. The Carbon Monoxide Detectors were tested and is operational.

[Continue to LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/15/2026
NARRATIVE
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Physical Plant/Environment Safety [Cont.]: LPA inspected eight (8) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. The outdoor area has a shaded area for activity purposes. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid mat/strips and shower chair. LPA tested hot water temperature in eight (8) random resident rooms (Rooms: 6, 8, 10, 12, 14, 17, 26, and 32) in the 1st and 2nd floors. Water temperature readings measured between 105.2 degrees F - 127.7 degrees F, which is not within the required temperature 105 to 120 degrees F. Stairwell evacuation chairs were observed.

Staffing: There are sufficient staff members to provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records/Staff Training: LPA reviewed six (6) staff files which include: Personnel Record, health screening, TB test results, Employee Rights, valid First Aid/CPR/AED Training, ongoing staff and Dementia training. The administrator’s certificate is valid and expires on 04/25/2028.

Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted in the 1st floor. Facility provides internet services to all residents and they have access to the facility phone.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted.

Food Service: Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept clean and stored properly. Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Per Administrator, there are Four (4) residents on modified diets. Physician orders are on file and special diet lists are kept in the kitchen area.

[Continue to LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/15/2026
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Incident Medical and Dental: LPA reviewed five (5) centrally stored resident medications which contain a 30-day supply of medications. Medical and dental transportation is provided. Based on Record Review, LPA observed and confirmed with the Administrator that Resident #1 (R1) is missing the following medications: Atorvastatin, Aripiprazole, Levofloxacin, Ferrous Sulfate, Ciclopirox, Ammonium Lactate, Selenium Sulfide, Nystatin, and Diclofenac Sodium. Based on Record Review, LPA observed that per Resident #2 (R2’s) physician’s report dated 2/6/2026, R2 is unable to administer their own medications and unable to administer their own injections. R2 requires injections for diabetes. Additionally, per Administrator interview, the facility has no skilled medical professional to administer injections.

Resident Records/Incident Reports: LPA reviewed five (5) resident files that include the face sheet, Identification and Emergency Information Form, Admission Agreements, Physician's Reports, Ambulatory Status, TB clearance, Physician's Orders, Preplacement Appraisal, Resident Appraisal, and Personal Rights.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills. The facility has a First Aid Kit with all required items.

Residents with Special Health Needs: Per Administrator, there are two (2) residents that receive hospice services and five (5) resident receives home health services. Per Administrator, there are 14 residents have a Dementia diagnosis and are located in the 1st floor. Postural support physician orders are on file. Full bed rails for mobility assistance were observed in some resident rooms and LPA reviewed resident files with bed rail orders. No residents have prohibited health conditions.

$ 250.00 Civil Penalty is being issued during today's visit as a result of a repeat violation within a 12-month period ( 87303(e)(2) ). LIC421FC provided to the Administrator during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator, Claudia Sanchez.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/15/2026 03:43 PM - It Cannot Be Edited


Created By: Daniel Konishi On 06/15/2026 at 03:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that water temperature readings in Room #s 6 (123.8 deg F), 8 (124.1 deg F), 10 (124.1 deg F), 26 (127.7 deg F) did not measure within the required 105 - 120 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 06/16/2026
Plan of Correction
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Administrator shall immediately adjust water temperature. Administrator to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105-degree F and 120 degrees F. Administrator will provide a copy of the log to the department once water temperature falls within Title 22 guidelines.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record Review, LPA observed and confirmed with the Admin that R1 is missing the following medications: Atorvastatin, Aripiprazole, Levofloxacin, Ferrous Sulfate, Ciclopirox, Ammonium Lactate, Selenium Sulfide, Nystatin, and Diclofenac Sodium. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2026
Plan of Correction
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Administrator will submit a plan to the LPA by the POC due date on how and when the facility will obtain Resident #1 (R1’s) missing medications. Administrator will send proof to the LPA that confirms the facility has R1’s medications by 6/29/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/15/2026 03:43 PM - It Cannot Be Edited


Created By: Daniel Konishi On 06/15/2026 at 03:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record Review, LPA observed that per Resident #2 (R2’s) physician’s report dated 2/6/2026, R2 is unable to administer their own medications and unable to administer their own injections. R2 requires injections for diabetes. Additionally, per Administrator interview, the facility has no appropriately skilled professional to administer injections. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2026
Plan of Correction
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Administrator will submit a plan to the LPA by the POC due date that explains how the facility will meet this regulation moving forward.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
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