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Inspection visit

Routine inspection (multi-day)

HENRIETTA'S LEVEN OAKSLicense 1986035863 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

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 used the CARE Inspection Tool to continue the 1 year required annual inspection, LPA reviewed medication for (3) residents and reviewed centralized medication log. No deficiency noted for medication review. LPA Calderon did staff file review for, a total of (5) files, five files were reviewed. LPA checked for clearance, personnel records, health screening, training and first aid/ cpr certification. During file record review the following was observed and cited: 1) Personnel records- for Staff # S3 did not contain a job application nor an LIC 501 personnel record and no physician health screening / tb report LIC 503 - Interm-Admin. Claudia Sanchez assisted LPA Calderon in locating documentation's and documentation's were not in S3 file. (2) Deficiency cited. 2) No clearance record for Staff #1(S1), LPA Calderon called LPM Fierros and Licensing Support Staff to verify clearance of S1, LIS did not contain records of S1 on the system, Facility Interm-Admin. Claudia Sanchez was unable to get record of S1 clearance status. Deficiency and Civil Penalty cited. LPA was will return on a later time to complete annual inspection. LPA will sent reports 809, (2) 809-D pages, Civil Rights, and Appeal Rights to Interm-Administrator Claudia Sanchez via email. Due to printer issues.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87355(e)(1)Type A

    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.

  • 87412(a)(11)Type B

    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.

  • 87412(a)(7)Type B

    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.

FAQ · About this visit

Common questions about this visit

What happened during the September 26, 2023 inspection of HENRIETTA'S LEVEN OAKS?

This was a other inspection of HENRIETTA'S LEVEN OAKS on September 26, 2023. 3 citations were issued: 1 Type A (serious) and 2 Type B.

Were any citations issued to HENRIETTA'S LEVEN OAKS on September 26, 2023?

Yes, 3 citations were issued (1 Type A, 2 Type B). The first citation was for: "Based on LPA Calderon and Interm-Administrator Claudia Sanchez record review Staff 1 (S1) did not have clearance record ..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.