191290642-4-25-2024-31-AS-NMAN-D4TPWS-20240430114112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:26:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/14/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240314085124

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	AARON KHODORKOVSKY		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 147	DATE:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	Brandy Rangel		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff yelled at resident.
Staff not keeping resident’s room free from odor.
Staff did not respond to resident’s pendant call.
Staff mismanaged residents medication.
Staff did not prevent outbreak of covid.
Staff does not prevent resident from being threatened by other residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Assistant Administrator, Brandy Rangel, and explained the reason for the visit.

--- Staff yelled at resident.

It was alleged that Staff #1 (S1) yelled at Resident #1 (R1). To investigate the allegation, on 03/20/2024 LPA interviewed four (04) staff 1:00 PM - 2:30 PM. On 04/25/2024, interviewed (14) fourteen residents from 11:30 AM to 1:00 PM. During interviews with staff, all staff stated they never yell at residents. During interviews with residents, R1 stated that Staff #1 (S1) yells at her and is rude.

(CONT. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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 4

Control Number 31-AS-20240314085124

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 04/25/2024

NARRATIVE

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All other residents stated staff do not yell at them and have never witnessed staff yelling at residents.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff not keeping resident’s room free from odor.

It was alleged that R1’s room has a mildew odor. To investigate the allegation, on 03/20/2024 LPA conducted physical plant tour at around 10:30 AM and interviewed four (04) staff 1:00 PM - 2:30 PM. On 04/25/2024, LPA interviewed (14) fourteen residents from 11:30 AM to 1:00 PM. During the physical plant tour, LPA did not experience any mildew odor or see any mildew. During interviews with staff, all staff stated they have never smelled mildew odor in the facility. During interviews with residents, R1 stated window a/c is filled with mildew and that it smells. All other residents stated they have not experienced any mildew odor.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff did not respond to resident’s pendant call.

It was alleged that staff do not respond to resident call buttons. To investigate the allegation, on 03/20/2024 LPA conducted a physical plant tour at around 10:30 AM and LPA interviewed four (04) staff 1:00 PM - 2:30 PM. On 04/25/2024, LPA interviewed (14) fourteen residents from 11:30 AM to 1:00 PM. During the physical plant tour, LPA randomly selected five (05) call pendants and observed an average response time of five (05) minutes. During interviews with staff, all staff stated they respond within three (03) to five (05) minutes. During interviews with residents, R1 stated there is nothing wrong with her pendant and staff do not respond at all. Seven (07) out of fourteen (14) residents stated they have a call button but do not use it. Three (03) out of fourteen (14) residents stated staff respond within five (05) minutes and three (03) out of fourteen (14) residents stated staff respond within ten (10) minutes.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
(CONT. LIC9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20240314085124

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 04/25/2024

NARRATIVE

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--- Staff did not give medication in a timely manner.

It was alleged that staff do not give residents medication timely. To investigate the allegation, on 03/20/2024 LPA interviewed four (04) staff 1:00 PM - 2:30 PM. On 04/25/2024, at around 10:15 AM, LPA requested records and interviewed (14) fourteen residents from 11:30 AM to 1:00 PM. The Medication Administration Records indicate that R1 received all medications as prescribed. During interviews with staff, all staff stated medications are given to residents timely. During interviews with residents, R1 stated they were told their medications were coming but never did and they had to go downstairs to get it. All other residents stated staff give medications timely.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff did not prevent outbreak of covid.

It was alleged that staff do not give residents medication timely. To investigate the allegation, on 03/20/2024 LPA interviewed four (04) staff 1:00 PM - 2:30 PM. On 04/25/2024, LPA reviewed the department’s records at 11:00 AM and interviewed (14) fourteen residents from 11:30 AM to 1:00 PM. During record review, the department’s Incident Report records do not indicate that an outbreak was reported in the past four (04) months. During interviews with staff, all staff stated the facility did not experience an outbreak in recent months. During interviews with residents, R1 stated that the entire floor was covid positive. All other residents stated they are not aware of any covid outbreak.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff does not prevent resident from being threatened by other residents.

It was alleged that Resident #1 (R1) was threatened by a resident. To investigate the allegation, on 03/20/2024 LPA interviewed four (04) staff 1:00 PM - 2:30 PM. On 04/25/2024, LPA interviewed (14) fourteen residents from 11:30 AM to 1:00 PM.
(CONT. LIC9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20240314085124

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 04/25/2024

NARRATIVE

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During interviews with staff, all staff stated they are not aware of any resident threatening other residents. During interviews with residents, R1 stated that R14 threatened them. All other residents, including R14, stated they have never threatened any residents and are not aware of residents threatening other residents.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No heath and safety hazards noted during the visit.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

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