191290642-1-30-2024-31-AS-NMAN-D2ESKJ-20240213125648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/30/2024
Date Signed: 01/30/2024 05:01:43 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
01/29/2024 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20240129141728

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	AARON KHODORKOVSKY		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(323) 697-2248
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 126	DATE:	01/30/2024
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Aaron Khodorkovsky, Administrator		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was sexually abused while in care

INVESTIGATION FINDINGS:

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

Licensing Program Analystt (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Aaron Khodorkovsky and explained the purpose of the visit.

It was reported that a resident was sexually abused while in care by an unknown individual at the facility. To investigate this allegation, on 1/30/2024 between 11:00am and 11:45am, staff interviews were initiated. Interviews revealed that Resident #1 (R1) has been living at the assisted living since 4/08/2022. On 1/25/2024, law enforcement came to the facility and interviewed R1. The interview did not reveal much since R1 could not name or identify the alleged perpetrator. Due to insufficient information the case was deemed unfounded. On 1/25/2024, R1 was also sent to the hospital due to an unwitnessed fall. On 1/30/2024, R1 was discharged from the hospital and sent to a skilled nursing facility, due to requiring a higher level of care. Staff told LPA that R1 has a history of making false allegations towards family, friends, and staff. Staff deny that a stranger was allowed into the facility and sent to R1's room to be sexually assaulted.
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: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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-20240129141728

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: 01/30/2024

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

Furthermore, between 12:00pm and 1:00pm, facility records were reviewed, Records confirmed what staff told LPA. R1 has been living at the faciity for almost two years and not one week as was previously reported.
LPA looked at admission agreement. In addition, R1's physician's report also confirms that they have a tendency to make false statement against others, due to being confused and disorientated.

Based on interviews and records review 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: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2