191290642-12-20-2023-31-AS-NMAN-CZUVKQ-20240126153043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:29:35 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
12/13/2023 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20231213161140

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	CELIA GARCIA		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(323) 697-2248
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 134	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Brandy Rangel, Assistant Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Assistant Administrator Brandy Rangel and explained the reason for the visit.

It was alleged that facility is in disrepair. It was reported that water from an unknown source was leaking into Resident #1 (R1)'s room. Furthermore, that water was causing mildew and spores to grow on the carpet and heater. To investigate this allegation on 12/20/2023, between 12:30pm and 1:00pm, LPA went to R1's room to observe the damage that was reported. LPA did not observe any damage to the carpet. LPA touched the carpet and it was not wet. The carpet was not discolored. It looked clean and in good condition. LPA had R1 turn on the heater and it was functional. Between 1:30pm and 2:00pm, staff interviews were initiated. Interviews revealed that on Saturday Dec. 2, 2023, in the middle of the night, they were called and informed that there was a water leak. A plumber was called in immediately to assess the situation.

Continue on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20231213161140

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: 12/20/2023

NARRATIVE

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The plumber determined that the source of the problem was coming from the room upstairs. A resident from the third floor was flushing wipes down the toilet. This caused damage to the pipes. The pipes were fixed by 6pm, on Dec. 3, 2023.

Based on observation and interviews there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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