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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 09/07/2023
Date Signed: 09/07/2023 05:39:17 PM


Document Has Been Signed on 09/07/2023 05:39 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: 131DATE:
09/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Celia Garcia, AdministratorTIME COMPLETED:
05:10 PM
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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.

Facility pool cords were non-operational.
Residents interviewed during this visit addressed their concerns about insufficient staffing

During this visit LPAs noted that insufficient staffing is affecting residents care, supervision, and medication assistance.

Due to non-working call system, residents were not getting the proper toileting assistance.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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


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: 09/07/2023
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The Facility did not report unusual incident that may affect resident’s health and safety to the Licensing Office.

Other note issues also were discussed with the Administrator, and she was informed that due to time constrains LPA and LPM were unable to address the deficiencies. Therefore, an additional visit will follow to address the deficiencies unrelated to the complaint.

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: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2