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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:59:19 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.ASC, 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
02/16/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 28-AS-20230216114416
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:CELIA GARCIAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(323) 697-2248
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 130DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Celia Garcia - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not ensure that resident receives the correct medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with administrator Celia Garcia and explained the reason for the visit.

LPA conducted physical plant tour at 9:38 AM, requested facility documents at 10:20 AM, interviewed staff and residents between 10:30 AM to 12:15 PM and reviewed records between 12:30 PM to 1:40 PM. Regarding the allegation that Staff do not ensure that resident receives the correct medication, it was alleged that Resident #1 (R1) was being provided with the medication that has been ordered by R1's physician to be held. LPA's record review today between 12:30 PM to 1:40 PM revealed that R1's physician, held a particular medication on 04/14/23 pending re evaluation of R1. Further review also revealed that the particular medication was administered to R1 beyond the hold date of 04/14/23. Based on the information gathered during this and prior visit, the allegation is deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted Copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 28-AS-20230216114416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2023
Section Cited
CCR
87465(c)(2)
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(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:

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Administrator agreed to conduct an in service to all the medication staff and submit proof of training on or before the POC date.
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Based on LPA's record review, the licensee did not ensure that the doctor's order to hold the medication was implemented as ordered. This poses an immediate health and safety risk to the resident in care.
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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: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
02/16/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 28-AS-20230216114416

FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:CELIA GARCIAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(323) 697-2248
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 130DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Celia Garcia - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not respond to resident's requests for assistance in a timely manner.
INVESTIGATION FINDINGS:
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5
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12
13
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with administrator Celia Garcia and explained the reason for the visit.

LPA conducted physical plant tour at 9:38 AM, requested facility documents at 10:20 AM, interviewed staff and residents between 10:30 AM to 12:15 PM and reviewed records between 12:30 PM to 1:40 PM. Regarding the allegation that Staff do not respond to resident's requests for assistance in a timely manner, it was alleged that Resident #1 (R1), on several occasions pulls cord to request assistance but nobody responded. LPA's interview on 02/21/23 with nine (9) residents and today with five (5) residents between 10:30 AM to 12:15 PM with a total of fourteen (14) residents or more than 10% of current census, revealed that ten (10) out of fifteen (15) residents stated that staff respond to their call for assistance whether by pull cord or by phone within five (5) to fifteen (15) minutes. Further, three (3) residents stated that they have not called for any assistance nor used the pull cord at any time during their stay. (continued on LIC 9099A-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230216114416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEISURE VALE RETIREMENT HOTEL
FACILITY NUMBER: 191290642
VISIT DATE: 09/19/2023
NARRATIVE
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(continued from LIC 9099-A)

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4