191290642-1-16-2024-28-AS-TAGD-CZRQ44-20240123104943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/16/2024
Date Signed: 01/16/2024 01:16:48 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
04/03/2023 and conducted by Evaluator Gina Saucedo

COMPLAINT CONTROL NUMBER: 28-AS-20230403141742

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:	12:26 PM
MET WITH:			TIME COMPLETED:	01:16 PM

ALLEGATION(S):

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Insufficient Supervision resulting in inappropriate behaviors by Resident.

INVESTIGATION FINDINGS:

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On 01/16/24, at 9:56am, 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: Insufficient supervision resulting in inpropriate behaviors by resident. It is being alleged that R1 was hit by another resident, was called an inappropriate name, and has been harassed by the same person.

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)

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Control Number 28-AS-20230403141742

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

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According to the resident and staff interviews there is no fighting and/or aggression allowed in the facility. R1 admits that the hit was not intended for them. Rather, it was meant for the former Administrator that is no longer working at the facility. R1 admits that they did intervene during a potential altercation. R1 wanted to help the former Administrator from potentially getting hit. Based on LPA's interview with R1, 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)

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