191290642-1-10-2024-31-AS-NMAN-CZUV5H-20240126150758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/10/2024
Date Signed: 01/10/2024 05:31:22 PM

Substantiated

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-20240102090300

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: 126	DATE:	01/10/2024
		UNANNOUNCED	TIME BEGAN:	11:13 AM
MET WITH:	Aaron Khordorkovsky, Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff did not ensure that facility is free of mold.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit to the facility for the above noted allegations. LPA met with Administrator Aaron Khordorkovsky and dicussed the purpose of the visit.

It was reported that staff did not ensure that facility is free of mold, To investigate this allegation on 1/10/2024, between 12:00pm and 1:00pm, LPA reviwed facility records. Records revealed that on 12/08/2023, R1 reported to the facility that there was mildew in the bathroom and that it smelled bad. On 12/11/2023, according to maintence records, the bathroom ceiling and wall was repaired. Also, on 12/12/2023, all the bathroom walls were painted. Furthermore, on 12/20/2023, LPA conducted an unannounced visit to the facility for another complaint and during the course of that investigation visited R1's room and observed that the bathroom was free of mold since it had been recently repaired.

Continue on 9099-C

Substantiated

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: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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 6

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-20240102090300

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: 126	DATE:	01/10/2024
		UNANNOUNCED	TIME BEGAN:	11:13 AM
MET WITH:	Aaron Khordorkovsky, Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff did not ensure that filters were changed at the facility.

Staff did not respond to a resident's emergency call button.

Staff did not supply a resident with appliances in a timely manner.

Staff supplied a resident with a medical device that contained cockroaches.

Facility has pests.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit to the facility for the above noted allegations. LPA met with Administrator Aaron Khordorkovsky and dicussed the purpose of the visit.

It was reported that staff did not ensure that filters were changed at the facility. To investigate this allegation on 1/10/2024, between 12:00pm and 1:00pm, LPA reviewed facility records. Records revealed that on 12/12/23, maintence workers installed a new AC filter in Resident #1 (R1's) room. On 12/20/23, LPA conducted an unannounced visit to the facility to investigate another complaint and during the course of that investigation inspected R1's room and observed that the filter had been replaced. In addition, LPA had R1 turn on the AC to see if it worked. LPA noted that both the AC and heater were operational.

Based on records review and observation, there is insufficient evidence to support this allegation. Thus, this allegation is deemed UNSUBSTANTIATED at this time.

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: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 31-AS-20240102090300

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: 01/10/2024

NARRATIVE

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It was alleged that staff did not respond to a resident's emergency call button. To investigate this allegation, on 1/10/2024 between 12:00pm and 1:00pm, LPA reviewed facility records. Records revealed that between 12/01/2023 and 1/09/2024, R1 used the emergency call button pendant twice. On 12/04/23 and on 12/05/2023, R1 used the call button to request assistance. Furthermore, the call log indicates the facility response status as completed and taken. Between 1:00pm and 1:30pm, LPA spoke to the administrator. Interview revealed that the call system was recently upgraded and is fully operational. In addition, facility staff have been trained to respond promptly to resident calls.

Based on interviews and records review there is not sufficient information to support this allegation. Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

It was reported that staff did not supply a resident with appliances in a timely manner. To investigate this allegation between 12:00pm and 1:00pm, LPA reviewed facility records. Records reveled that on 10/06/2022, R1 signed an Assisted Living Waiver Amenity Form, where they waived their right to get a refrigerator and a microwave oven. In addition, between 1:00pm an 1:30pm, LPA interviewed facility administrator. Interview revealed that on 12/22/2023, R1 was given a new microwave oven.

Based on interviews and records review there is not sufficient information to support this allegation. Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

It was alleged that staff supplied a resident with a medical device that contained cockroaches. To investigate this allegation on 1/10/20023, between 12:00pm and 1:00pm, LPA reviewed facility records. Records revealed that on 11/18/2022, R1 informed the pharmacy to not send non-covered medications or medications with co-pays as they will not pay. Moreover, on 12/26/2023, R1's medical insurance rejected to pay the pharmacy for a new nebulizer compressor. As a courtesy, the facility offered and paid the $45.00 bill for the new nebulizer. The new nebulizer was delivered to R1 on 1/08/2024. Between 1:00pm and 1:30pm. LPA spoke to the administrator. Interview revealed that the facility never gave a used cockroach invested nebulizer to R1. Staff does not know how R1 obtained a used dirty nebulizer.

Based on interviews and records review there is not sufficient information to support this allegation. Therefore, this allegation is deemed UNSUBSTANTIATED at this time

Continue on 9099-C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 31-AS-20240102090300

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: 01/10/2024

NARRATIVE

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It was reported that facility has pests. To investigate this allegation between 12:00pm and 1:00pm, LPA reviewed facility records. Records revealed that the facility has contracted a fumigation company to come to the facility monthly to fumigate. Facility provided LPA with three months worth of invoices as proof that the facility is being fumigated. In addition, LPA has gone out to the facility on multiple occasions and conducted several physical plant tours and has not observed any pests while conducting investigations.

Based on records review and observation, there is not sufficient information to support this allegation. Therefore, this allegation is deemed 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: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20240102090300

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: 01/10/2024

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	Based on records review and observation, there is sufficient information to verify this allegation. Therefore, this allegation is SUBSTANTIATED at this time. Per Title 22 regulations, a citation is being issued today, but it is also being cleared today since the violation has already been corrected. Exit interview conducted and a copy of the report has been issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20240102090300

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/10/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintence & Operation-(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidence by:	1 2 3 4 5 6 7	This citation has been cleared on this visit.. On 12/20/2023, LPA did not observe any mildew in R1's bathroom, since it had already been repair.
	8 9 10 11 12 13 14	There was mildew in R1's bathroom. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

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