191290642-10-18-2023-31-AS-NMAN-D5CUUZ-20240517155423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 10/18/2023
Date Signed: 10/18/2023 03:47:42 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
10/12/2023 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20231012114227

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: 134	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Aaron Khodorkovsky, Interim Administrator		TIME COMPLETED:	03:36 PM

ALLEGATION(S):

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Staff are mismanaging residents medication

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Rosaura Valenzuela and Gina Saucedo conducted an unannounced complaint investigation for the above noted allegation. LPAs met with Interim Administrator Aaron Khodorkovsky and discussed the purpose of the visit.

It was reported that staff are mismanaging residents medication. To investigate this allegation on 10/18/2023 between 1:00pm and 1:30pm, staff iinterviews were initiated. Interviews revealed that an inservice training for existing med-techs regarding policy and procedure was conducted on 10/12/2023. Between 1:30pm and 2:00pm, LPAs reviewed facility records. Records confirmed what staff told LPAs. Between 3:15pm and 3:25pm, resident interviews were initiated. Resident interviews revealed that staff has made multiple medicatiion errors in the last couple of months, but that presently they are making an effort to improve the way medication is being dispensed.

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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 31-AS-20231012114227

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: 10/18/2023

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 interviews and records review there is sufficient information to verify this allegation. Therefore, this allegation is being SUBSTANTIATED at this time. Facility will not be cited at this time due to documentation presented during this visit regarding medication training that was provided to staff on 10/12/2023. 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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

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