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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/09/2024
Date Signed: 01/09/2024 05:02:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/02/2024 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20240102152557
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:CELIA GARCIAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(323) 697-2248
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Aaron Khordorkovsky, AdministratorTIME COMPLETED:
03:26 PM
ALLEGATION(S):
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Facility is retaliating against a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Admistrator Aaron Khordorkovsky and explained the reason for the visit.

It was reported that facility is retaliating against a resident in care due to filing complaints to licening against the board and care. To investigate this allegation on 1/09/2024, at 10:45am, LPA requested Resident #1 (R1's) most up to date medical records. Between 11:00am and 12:00pm, R1's medical records were reviewed. Records revealed that R1 was placed on a 5150 hold due to being gravely disabled and displaying aggressive behavior. A medical doctor affirmed the diagnosis. Between 12:00pm and 1:00pm, LPA interviewed the Administrator. Interviews confirm what medical recordsl stated. R1 was sent to the hospital for a psychiatric evaluation due to being psychotic and having delusional thoughts. In addition, per Administrator, R1 requires a higher level of care that the facility can not provide. The faciity is not retaliating against R1, but rather wants them to receive treatment and a higher level of care.
Contiue on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20240102152557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEISURE VALE RETIREMENT HOTEL
FACILITY NUMBER: 191290642
VISIT DATE: 01/09/2024
NARRATIVE
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Based on interviews and records review there is sufficient information to not verify this allegation. Thus, this allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2