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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 10/23/2023
Date Signed: 10/23/2023 05:12:01 PM


Document Has Been Signed on 10/23/2023 05:12 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:
10/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Aaron Khodorkovsky, Interim AdministratorTIME COMPLETED:
05:16 PM
NARRATIVE
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A Case Management unannounced visit is being conducted to address Title 22 deficiencies noted in the facility during licensing visits.

Moreover, this Case Management visit is conducted in conjunction with a complaint investigation visit to address the issues unrelated to the complaint.

On 10/23/2023 at 11:30am, Licensing Program Analyst (LPA) Rosaura Valenzuela and Licensing Program Manager (LPM) Naira Margaryan requested facility records. Records revealed that a former employee was hired without obtaining a health screening. The T.B test for staff #1 (S1) was incomplete.

Also, the facility did not report a serious incidents involving Resident #1 (R1) and staff #1 (S1), that mat potentially effect R1 and other residents health, safety, and personal rights.
Citations cited on 9099-D page.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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 10/23/2023 05:12 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: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2023
Section Cited
CCR
87211(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, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...within seven days of occurrence of any of the events specified...
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The Licensee will tell the department in writing how they will ensure that they will report all incidents that occur at the facility to Licensing.
This will be submitted by 11/06/2023.
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(D) Any incidient which threatens the welfare, safety, or health of any resident, such as psychological abuse of a resident by staff ...
This requirement was not met as evidenced by: The Licensee did not report financial abuse by staff toward residents. This poses a potential health and safety risk to residents in care.
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Type B
11/06/2023
Section Cited
CCR87412(a)(11)

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87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personel record shall contain the following information; (11) A health screening as specified in Sec. 87411, Personnel Requiremets-General
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The licensee shall submit in writing to licensing how they will ensure that all staff are health screened prior to being employed at the facility. This will be submitted by 11/06/2023.
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This requirement was not met as evidenced by:

A former staff member had an incomplete T.B. test on their file.
This poses a potential health and safety risk 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: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2