191290642-1-16-2024-28-AS-MVAO-CZYUUT-20240130145403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/16/2024
Date Signed: 01/16/2024 01:15:19 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
03/20/2023 and conducted by Evaluator Gina Saucedo

COMPLAINT CONTROL NUMBER: 28-AS-20230320135626

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: 135	DATE:	01/16/2024
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Brandy Rangel		TIME COMPLETED:	01:18 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is in disrepair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/16/24, at 9:55am, Licensing Program Analyst (LPA) Gina Saucedo and Licensing Program Manager (LPM) Troy Agard arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Nilda Mercado-Business Manager.

LPA Saucedo asked for the census for staff, and resident files. The Assistant Administrator, Brandy Rangel met with LPA Saucedo to conduct the physical tour at 10:20 am and interviews. During the tour 10 (ten) residents and four (4) staff were interviewed.

Regarding the allegation: Facility is in disrepair. It is being alleged that R1 has electric wires on the other side of the wall and the panel in hallway outside of the door is open. Based on the resident and staff interviews, there is a maintenance book at the front register to document the resident's name, room number

9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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 28-AS-20230320135626

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: 01/16/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

and what needs to be repaired. In addition, the residents can call the front desk to report any maintenance issues/repairs that is needed. During facility tour, LPA did not observe any electrical wires by R1's room or any panel area around R1's room open. Therefore, the allegation(s) above is unsubstantiated at this time.

An exit interview was conducted, no citations were issued for above allegation(s), and a copy of this report was given to the assistant administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2