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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 10/05/2023
Date Signed: 10/05/2023 05:24:34 PM


Document Has Been Signed on 10/05/2023 05:24 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 134DATE:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Aaron Khodorkovsky, Interim AdministratorTIME COMPLETED:
05:24 PM
NARRATIVE
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This case management visit is conducted to address Title 22 deficiencies noted in the facility during various licensing visits.

This Case Management visit is conducted in conjunction with complaint investigation visit to address the issues unrelated to the complaint.

On 09/07/23 at 9:30am, LPM Margaryan and LPA Valenzuela observed the garage to be fully obstructed with construction materials, old torn pieces of carpets, old pieces of furniture and other debris. (The garage was cleaned during this visit)

While inspecting the facility LPM and LPA noted the holes on the walls and exposed loose wiring that could pose hazard to the residents. (This deficiency was corrected during visit).

During various Licensing visits different LPAs noted that insufficient staffing is affecting residents care, supervision, and medication assistance.
This issue was addressed on 09/07/2023 while Licensing Office was conducting an investigation alleging “Due to insufficient staffing residents needs are not met”.
The allegation was substantiated, and citation was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/05/2023
NARRATIVE
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Due to non-working call system, residents were not getting the assistance in timely fashion. At the time of this visit the call system was still not working.

The Facility did not report unusual incident that may affect resident’s health and safety to the Licensing Office. Illegal drugs were confiscated from the residents’ room and Licensing Office was not notified and police was not contacted.

During today's visit LPA reviewed resident’s roster and noted that the facility retains 40 residents that that were underage of 60.
11 out of 40 residents were underage of 50 and 29 were between the ages of 51 to 59.
At the time of this visit between 10:00am and 2:00pm, LPA Valenzuela reviewed 11 out of 40 records. Upon review of the records LPA noted following;
1.Residents’ preadmission appraisal, need and service plans were missing.
The documentation reviewed during this visit did not provide the information to determine that need of the population that are underage of 60 are compatible with other residents in care

No other health and safety hazard are noted during this visit.
Exit interview was conducted and a copy of report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 05:24 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
WOODLAND HILLS S.RO, 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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2023
Section Cited
CCR
87303(i)(1)(B)

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87303 Maintenance and Operation. (i) Facilties shall have signal systems which meet the following criteria: (1) All facilties licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal atthe living unit loud enough to summon staff.
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The interim Administrator stated that call system is being repaired. Currently they assigned specific staff to walk through the whole facility to assist residents if needed. This citation is cleared during this visit.
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This requirement was not met as evidenced by: The facility signal system in the residents rooms were tested and appeared to be non-operational. This poses an immediate health and safety hazard to residents in care.
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Type B
10/19/2023
Section Cited
CCR7506(a)

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7506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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Licensee will inform in writing about the steps they will take to complete all residents records. Tentative time frame will be provided to inform about the completion of all records.
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Licensee did not ensure to maintain complete records for facility residents. This posses a potential health and safety hazard to residents 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 05:24 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
WOODLAND HILLS S.RO, 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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
87455(b)(7)

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87455 Acceptance and Retention Limitations (b) The following persons may be acceptd or retained in the facility: (7) Persons who are under 60 years of age whose needs are comparable with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility. This requirement is not met as evidenced by:
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The interim Administrator will conduct full appraisal of all residents that are under 60 years of age to determine the need of the residents. The records will be updated as needed. Special plan will be implemented to relocate the residents whose care needs are not compatible to others. Will tell CCL in writing,
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Over 30% of the facility residents are under 60 years of age and there is not information or records to determine if their needs are comparable to the care provided to other residents. This poses potential risk to the health, safety, and personal rights to residents in care.
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Type B
10/19/2023
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require;;;(1) A written report shall be submitted to the licensing agency and to the person responsbile for the resident within seven days of the occurrence of any...events...(D) Any incident which threatens the welfare, safety, or health of any resident. This requirement was not met as evidenced by:
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Administrator will review Title 22 reporting requirements, provide training to staff, and moving foward all incidents will be reported as required. POC must be provided in writing.
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Staff found illegal drugs in resident's room that has history of drug abuse and CCL was not notified. This poses a potential risk to the health, safety, and personal rights to residents 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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