HENRIETTA'S LEVEN OAKS

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 06/16/2026 Plan of Correction 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.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 06/16/2026 Plan of Correction 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.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 06/16/2026 Plan of Correction Administrator will submit a plan to the LPA by the POC due date that explains how the facility will meet this regulation moving forward.

Official classification

Type A

Official code

87413(a)(2)

Regulation authority

CCR

What the official deficiency says

Personnel Operations Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by: Based on interviews conducted and information gathered Licensee failed to ensure that R1 was free from physical or verbal abuse, exploitation or prejudice with S1 using R1's credit card which was an Immediate Health and Safety Risk to residents in care.

Official plan of correction

Facility to submit a plan by POC due date which outlines how facility will handle going forward on how to safeguard residents finances. Deficiency cleared 03/26/26.

Deadline recorded: Mar 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interviews conducted and information gathered Licensee failed to ensure that R1 was free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature with S1 using R1's credit card which was an Immediate Health and Safety risk to residents in care.

Official plan of correction

Facility to submit a plan by POC due date which outlines how facility will handle going forward on how to safeguard residents finances.

Deadline recorded: Mar 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 hot water used by residents to attain a temperature of not less than 105-degree F (41 degree C) and not more than 120-degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA tested hot water temperature in eight (8) random resident rooms’ bathrooms (Rooms: 1, 7, 9, 11, 14, 22, 30 and B-1) in the 1st and 2nd floors and water temperature readings measured between 107.9 degrees F to 121.6 degrees F, which is not within the required temperature 105 to 120 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Administrator shall immediately adjust the 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.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on observation, LPA measured water temperature in bathroom #5 at 142.1 Degrees F which is not within Title 22 Regulations. This poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator shall immediately adjust water temperature. Licensee 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 LPA once water temperature falls within Title 22 guidelines.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation during the initial visit dated on 2/7/2025, LPA observed construction workers working on the 2nd floor and noticed tools such as hammers, mallets, drills, vacuum cleaners, wires, and vinyl flooring tiles in the hallway which are potential trip and fall hazards which poses an immediate health, safety, or personal rights in care.

Official plan of correction

Administrator will ensure to keep indoor passageways clear and free of obstruction and provide a photo of the hallways to the LPA by POC due date.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by: Based on observation, the bathroom in Rm#11 had a showerhead that was not working properly with water pressure was insufficient for a resident to take a shower. The bathroom in Rm#29 also was clean and well-kept but had a very foul odor from an unknown source. This poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will submit a photo of the showerhead working properly and photo of the clean bathroom in rm#29 to the LPA by the POC due date.

Deadline recorded: Apr 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

FIRE SAFETY All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that a total of 5 out of 20 resident rooms inspected did not have smoke detectors with batteries, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee shall ensure all resident room smoke detectors are operational. Provide a written plan of correction by tomorrow that states how the deficiency was corrected. *Note: Maintenance staff was observed replacing batteries during the visit.

Official classification

Type A

Official code

87303

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (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 Based on observation, the licensee did not comply with the section cited above in that hot water temperature readings in resident rooms ranged between 92.8 DF - 136.9, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Submit a water temperature log of all resident rooms. Readings must be within 105-120DF.

Official classification

Type B

Official code

87216(a)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above because P & I monies are handled and there is no Surety Bond in place, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2024 Plan of Correction Licensee shall obtain a Surety Bond and submit proof by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, licensee did not comply with the section cited above in that 11 discarded mattresses and 2 nightstands were observed in the parking lot area, as well as 1 electrical outlet near the laundry area and in the conference room did not have a covering, and rm B1 had a broken toilet, which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2024 Plan of Correction Submit picture proof evidence that all the discarded furniture has been removed, electrical outlets have coverings, and plan to fix room B1's toilet.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that the majority of all resident beds that were inspected did not have mattress pads, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2024 Plan of Correction Administrator shall submit a purchase order receipt and pictures of mattress pads on resident beds.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements - (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: During complaint investigation it was revealed that facility did no submit a Special Incident Report to Licensing as Administrator stated they were waiting for instructions from DHS on how to proceed.

Official plan of correction

Administrator to review Reporting Requirements as specified in Title 22 Regulations and complete the LIC9098 stating that they are knowledgeable in all reporting requirements once reviewed and submit completed LIC9098 to LPA via email by POC due date. Administrator to practice reporting requirements moving forward and submit a speical incident report to licensing pertaining this insident via fax.

Deadline recorded: Jan 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance 87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Calderon and Interm-Administrator Claudia Sanchez record review Staff 1 (S1) did not have clearance record , doj response and was not associated on LIS/ Guardian, no records of clearance record for S1 on file, the licensee did not comply with the section cited above in 35 out of 35 residents/ persons which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2023 Plan of Correction Interm-Administrator Claudia Sanchez notified LPA Calderon that she will be making the decision for Staff 1 (S1) to end shift today on 9/26/23 as S1 is on schedule and facility is waiting fingerprint status and will wait for clearance and will get S1 associated prior for S1 return to the above facility. Interm-Administrator Claudia Sanchez notified LPA that S1 went to get fingerprints on 9/25/23. Interm-Administrator Claudia Sanchez will sent LPA Calderon proof of S1 Clearance Status and Association via Guardian once cleared.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Calderon and Interm-Administrator Claudia Sanchez for staff #3 (S3) record review S3 did not have helath screening / tb in staff file upon review, the licensee did not comply with the section cited above in 35 out of 35 residents/ persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Interm-Administrator Claudia Sanchez during LPA's visit informed S3 to obtain health screening form the Clinic. Interm-Administrator Claudia Sanchez will obtain documenation and provide LPA Calderon with a copy via email by POC date.

Official classification

Type B

Official code

87412(a)(7)

Regulation authority

CCR

What the official deficiency says

Personnel Records 87412(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (7) Past experience, including types of employment and former employers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Calderon and Interm-Administrator Claudia Sanchez for staff #3 (S3) record review S3 did not have job application or personnel record in staff file upon review, the licensee did not comply with the section cited above in 35 out of 35 residents/ persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Interm-Administrator Claudia Sanchez for staff #3 (S3) will provide S3 with LIC501 or Job App to complete, once completed Claudia Sanchez will provide LPA Calderon a copy via email by POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Calderon and Interm-Administrator Claudia Sanchez observations, the following was observed: cleaning solutions, disinfectants, and chemicals were left out in the cleaning cart found unattended near building B, cleaning products were found accessible to residents in care. The licensee did not comply with the section cited above in 35 out of 35 persons/ residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2023 Plan of Correction Interm-Administrator Claudia Sanchez immediately locked cart in a closed off locked area. Facility will provide LPA Calderon with an in-service training material and staff sign in sheet regarding Title 22 Section 87309, to be submitted to LPA by 10/6/23.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Calderon and Interm-Adminstrator Claudia Sanchez observations the following was observed. Patio deck was found to have (4) ripped chairs and ladder left in patio leading to the roof top. Shed with storage items, shovel and oxygen tanks left unlocked and accessible to clients in care. Facility has spider webs and dirt on railings, in the patio roof awnings in Building B and patio next to dining room. Outside patio has spider webs, dirt and debris on outside furniture(s) chairs, bbq, table and awning. , the licensee did not comply with the section cited above in 35 out of 35 residents/persons, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Administrator will provide a in-service training on Section 87303 and provide LPA Calderon with in-service training topic materials, sign in sheet to LPA by POC due date. Facility will provide LPA with images of cleaned awenings, cleaned patio(s) furiture, locked latch for shed.

Official classification

Type B

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

87705(c)(4) Care Of Persons With Dementia: 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 was not met as evidenced by: Staff were not aware of residents whereabouts. Resident #1 and Resident #2 disappeared and were not on the facility premisis when caregivers went to check on residents.

Official plan of correction

Licensee /Administrator shall: ensure that all staff are trained on the responsibility of providing care and supervision. Administrator will conduct an in service with all staff, and will provide proof of training to LPA Calderon by POC due date.

Deadline recorded: Sep 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.2(c)

Regulation authority

HSC

What the official deficiency says

Health and Safety Code- Defintions: 1569.2(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This was not met as evidenced by: Staff were not aware of residents whereabouts. Resident #1 and Resident #2 disappeared and were not on the facility premisis when caregivers went to check on residents.

Official plan of correction

Licensee /Administrator shall: ensure that all staff are trained on the responsibility of providing care and supervision. Administrator will conduct an in service with all staff, and will provide proof of training to LPA Calderon by POC due date.

Deadline recorded: May 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... This requirement was not met evidenced by: Based on interviews conducted, staff take a long time to respond to resident calls; which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall: 1. Develop a plan to ensure staffing is compentent and staff receive continuous training in care responsibilities. 2. Conduct staff training Submit proof by POC due date.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements. The following food service requirements shall apply:Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met evidenced by: Based on record review and interviews conducted, the facility fails to provide R1 physician ordered special diet and a cultural/religious diet that meets dietary standards and physician order; which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall: 1.Consult with a Registered Dietician to formulate special diet foods for R1 2. Submit proof that kitchen staff have food handling certificates 3. Submit a written plan of how the deficiency was corrected.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement was not met evidenced by: Based on interviews conducted and physical plant observation rooms 28-29, and B1- & B2 have hot water issues and/or plumbing leaks; which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall provide: 1. A written plan of how the deficiency was corrected. 2. Copy of Plumbing Invoice Report **If an extension is needed submit a POC extension request by POC due date.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have communications to the licensee from their representatives answered promptly and appropriately. Based on record review, facility Administrator failed to respond to R1's Ombudsman representative in a timely manner. Ombudsman made two (2) facility visits, 2 telephone messages, and sent 1 email and did not receive a response; which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall submit a written plan of correction, and proof that the Ombudsman has been contacted.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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)

Deadline recorded: Jan 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

8775(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by; On 8/31/22, at 10:45am, LPA observed that the auditory chime device located on the front door was inoperable. This presents an immediate health and safety concern for the residents in care as the facility cares for residents with dementia.

Official plan of correction

During this visit, the Executive Director replaced the batteries on the auditory chime making it operable. Citation was cleared at the time of visit.

Deadline recorded: Aug 31, 2022. A deadline is not proof that correction was completed.