191290642-11-3-2023-31-AS-RVAA-CX8PNN-20231103112812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 11/03/2023
Date Signed: 11/03/2023 11:29:14 AM

Document Has Been Signed on 11/03/2023 11:29 AM - 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 HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	CELIA GARCIA		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(323) 697-2248
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 131	DATE:	11/03/2023
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Aaron Khodorkovsky, Interim Administrator		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An Informal Conference was conducted today at the Woodland Hills-South Adult and Senior Care Regional Office. This Informal Conference was held to discuss the licensee's high volume of complaints and to find possible solutions to help remedy these issues. Prior to the meeting, Licensee was given the chance to review the facility file. Present at today's meeting were the following: -Aaron Khodorkovsky, Interim Administrator -Jennifer Siegal, LVN Wellness Director -Alisa Berdnick, BV General -Naira Margaryan, Licensing Program Manager (LPM) -Rosaura Valenzuela, Licensing Program Analyst (LPA) The Informal Conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions. BRIEF HISTORY: The facility Leisure Vale Retirement Hotel has been in operation since licensure on 4/01/1993.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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: 11/03/2023

NARRATIVE

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Within the last three years, the facility has had the same or similar issues listed below. This is a list of citations issued within the last in the last two years.

03/09/22-87303(i)(1)(B) Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

04/21/22-87465(c)(2)-87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) once ordered by the physician the medication is given according to the physician's directions.

01/12/23 Personal Rights.-87468.1 (a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

06/21/23-87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.

08/11/23-87411(a)(1)- 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 (Resdient was admitted on 12/08/2020)

09/27/23- 87411 Personnel Requirements-(a) Facility personal shall at all times be sufficient in number, and competent to provide the services necessary to meet residents needs...insufficient staffing

08/18/23-78465(c)(2)-78465-Incidental Medical & Dental Care(c)(2) Once ordered by the physician the medication is given according to the physician's orders.

10/05/23-78465(c)(2)-78465-Incidental Medical & Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's orders

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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: 11/03/2023

NARRATIVE

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10/05/23-87303(i)(1)(B)-87303 Maintenance and Operation. (i) Facilities shall have signal systems which meet the following criteria: (1) All facilities 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 at the living unit loud enough to summon staff.

During this meeting, LPM Margaryan and LPA Valenzuela had an extensive discussion with facility representatives about the non-compliance history of the facility and the ways to bring the high complaint volume down.

LPM told facility representatives to reach out to our office for any questions.

In addition, during this meeting insufficient staffing was discussed. Also, repeat non-compliance with the submission of required serious incident reports to Licensing was discussed.

The interim administrator assured CCLD representatives that they will do everything in their power to bring the facilities into compliance under Title 22 regulations.

Interim administrator and Regional Wellness Director provided LPM and LPA with the extensive plans to bring facility in compliance with regulations.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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