191290642-5-11-2024-31-AS-NMAN-D5KS4S-20240524133314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 05/11/2024
Date Signed: 05/11/2024 02:47:45 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
03/20/2024 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20240320140318

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:	0	CENSUS: 144	DATE:	05/11/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Rosie Carrillo		TIME COMPLETED:	02:57 PM

ALLEGATION(S):

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Staff financially abused resident in care
Staff did not ensure that resident received their mail

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced subsequent complaint visit to the facility on 05/11/2024. LPA met with facility staff and disclosed the purpose of the visit. The administrator was not present at the facility. The administrator was contacted and authorized staff to sign.
During initial visit, on 03/26/2024, LPA Smith conducted tour of physical plant tour, conducted interviews, and requested documents relevant to the investigation from approximately 11:15 am to 12:55 pm.

Staff financially abused resident in care.

It was alleged that staff#1 (S1) financially abused resident #1 (R1) by taking R1s check and cashing it. To investigate the above allegation LPA Smith conducted a 10-day initial complaint visit. During initial visit, on 03/26/2024, LPA Smith conducted tour of physical plant tour, conducted interviews, and requested documents relevant to the investigation from approximately 11:15 am to 12:55 pm. R1 was not present at

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024

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-20240320140318

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: 05/11/2024

NARRATIVE

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Cont from 9099)

time of visits for an interview. Interview with two (2) of two (2) staff reveal R1 was a previously conserved resident. Staff #2 (S2) also revealed did not receive the conservatorship termination information until 03/18/2023 by R1 and R1s check was taken to the bank on 03/15/2024. S2 admitted to failing to closely inspect the check for correct recipient and deposited the check according to conserved protocols for the facility. Staff revealed due to scheduling a conflict on 03/15/24, R1 did not receive the funds until 03/20/24. LPA Smith reviewed Record of clients safeguarded cash resources and observed that R1 received payment on 03/20/24 and conservatorship termination letter dated 03/20/24 is in file. Two (2) of two (2) staff deny any malicious intent to financially abuse R1 and returned funds promptly.

Based interviews and record review although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Staff did not ensure that resident received their mail

It was alleged that staff did not ensure that resident received their mail. Interview with two (2) of two (2) staff revealed that the mail is held at a central point to prevent any lost or stolen mail. Then office staff sort and distribute mail to the residents. Interview with seven (7) out of seven (7) residents reveal they receive their mail and have not had and issue with receiving their mail that comes to the facility.

Based interview and record review although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted/copy of report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024

LIC9099 (FAS) - (06/04)

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