197610442-4-30-2024-31-AS-RVAA-D4TSG9-20240430135134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610442
Report Date: 02/22/2024
Date Signed: 04/30/2024 01:51:44 PM

Document Has Been Signed on 04/30/2024 01:51 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 GROVE, LLC		FACILITY NUMBER:	197610442
ADMINISTRATOR:	KHODORKOVSKY, AARON		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS STREET		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 143	DATE:	02/22/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Aaron Khodorkovsky, Administrator		TIME COMPLETED:	04:39 PM

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Licensing Program Analysts (LPAs) Rosaura Valenzuela and Abeye Duguma arrived at the facility on 02/22/2024 at 10:30 a.m. to conduct an announced Pre-Licensing visit and met with Administrator Aaron Khodorkovsky, Entrance interview conducted with the administrator and explained the purpose of today’s visit.

Today's site visit consisted of the LPAs and administrator touring the physical plant at 10:30 a.m. inside and outside the following was observed: The facility has one main entrance being used. The facility is a three floor building. The facility temperature observed to be in the range of 72 to 76 degrees Fahrenheit. The telephone on the premises is operational and functioning. The emergency exit plan/sketch is posted on the walls throughout the building.

Kitchen: At approximately 11:00 a.m. LPAs observed the kitchen area by the dining room to be clean. Appliances observed; sink and refrigerator and stove appeared to be in good repair and functional. The food is prepared at the facility. The food is then placed in large serving trays and transported in a large sealed cart and then individually served to residents at this facility.

Bedrooms: At approximately 11:30 a.m. LPAs inspected fifteen (15) random bedrooms all were observed to be clean and appropriately furnished and equipped with adequate lighting, bedroom furniture and linens. LPA observed the call light system to be on the front desk. Screen doors and window coverings were observed during the time of inspection to be in good condition

Bathrooms: LPA observed bathrooms located inside resident bedrooms to have non-skid shower flooring and appropriate grab bars installed in shower and around the toilet. At 11:50 a.m. hot water was tested in bathrooms and measured at 119.9*F.

Continued on LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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 GROVE, LLC	FACILITY NUMBER: 197610442
	VISIT DATE: 02/22/2024

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Medications: At approximately 11:45 a.m. the medication room was observed to be locked and inaccessible to residents. Medications were kept locked in a medication cart. Medication records are kept in files. LPA observed the First Aid Kit and Manual stored in the medication room.

Resident and Staff Records: Records are kept stored and locked in the office of facility.

Common areas: LPAs observed television areas to be clean and clear of clutter. LPAs observed elevator to be operational. LPAs observed fire extinguishers through out the facility with last serviced date of 11/19/2023. LPAs observed smoke/carbon monoxide detectors to be interconnected through out the facility. Dining Area was observed clean and have enough tables and chairs to sit the capacity of the facility.

Surroundings: LPAs observed the outside and surrounding area of the facility to be clean and clear from debris and obstruction.

. "Pre-Licensing is complete and this facility has no deficiencies." Component III was also completed.

Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

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