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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 08/11/2023
Date Signed: 08/11/2023 05:30:49 PM


Document Has Been Signed on 08/11/2023 05:30 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
Lookup Error,
, CA



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: 121DATE:
08/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:17 PM
MET WITH:Celia Garcia, administratorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced case management visit due to deficiencies observed during a visit at the facility. LPA met Administrator, Celia Garcia and explained the purpose of today's visit.

During today's visit, LPA reviewed facility files and interviewed staff. Per facility file reviews and staff interview, it revealed facility admitted resident#1 (R1) on 12/08/20 who had prohibited health conditions of stage 3 pressure injury. R1 received home health care; however, R1 was not on hospice. Facility did not apply and request an exceptions for accepting resident with prohibited health conditions from Licensing.

Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 809D.

An exit interview was conducted with Administrator. A hard copy of this report and appeal right were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/11/2023 05:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA


FACILITY NAME: LEISURE VALE RETIREMENT HOTEL
FACILITY NUMBER: 191290642

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2023
Section Cited
CCR
87615(a)(1)

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Persons who require health services for or have a health condition including,.. shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries

This requirement was not met by evidence of:
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Licensee will ensure that the facility is in compliance when admitting or retaining residents who had probited health conditions. The Licensee will submit a written plan of action that will be implemented to ensure that the facility would be in compliance by POC due date.
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Administrator accepted resident who had stage 3 pressure injury to the facility on 12/8/20 without having an approved Exceptions from Licensing. This poses an immediate health and safety risk to residents.
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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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2