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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 02/01/2023
Date Signed: 02/01/2023 01:50:17 PM


Document Has Been Signed on 02/01/2023 01:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA



FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:CELIA GARCIAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 91DATE:
02/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Celia Garcia TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Troy Agard made an unannounced Case Management - Incident visit to the facility listed above for the purpose of investigating a special incident. LPA met with Administrator, Celia Garcia and explained the reason for this visit.

The Woodland Hills South Regional Office received a report on 01/24/2023 regarding an incident that occurred on 01/17/2023 concerning missing medication for a resident in care. LPA Agard conducted interviews and a review of the medication administration log for R1.

LPA Agard advised that a subsequent visit regarding the incident may be conducted.

An exit interview was held, and a copy of this report was provided.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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