Henrietta's Leven Oaks

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.

(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.

(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.

(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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Care of Persons with DementiaLicensees 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.

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.