197610442-5-12-2025-31-AS-TAGD-DGUKLK-20250520080003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 05/12/2025
Date Signed: 05/12/2025 10:02:45 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2025 and conducted by Evaluator Angelica Segovia

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250414152217

FACILITY NAME:	LEISURE VALE ASSISTED LIVING		FACILITY NUMBER:	197610442
ADMINISTRATOR:	ANGELA SMITH		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS STREET		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 173	DATE:	05/12/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Angela Smith-Executive Director		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Staff did not respond timely to a resident's emergency alerts.
Staff did not provide required medical attention to a resident.
Staff did not properly maintain a resident's room.

INVESTIGATION FINDINGS:

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On 5/12/2025 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility.

LPA was greeted by the Executive Director (ED), Angela Smith and stated the reason for their visit was to deliver the findings of the complaint.

To investigate the allegation(s), on 4/23/2025 LPA and Licensing Program Manager (LPM) Troy Agard conducted a physical plant tour, requested pertinent documentation, and conducted interviews with eleven (11) residents (R1-R11) and six (6) staff members (S1-S6).

(Continue to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 31-AS-20250414152217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING	FACILITY NUMBER: 197610442
	VISIT DATE: 05/12/2025

NARRATIVE

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Regarding the allegation: Staff did not respond timely to a resident's emergency alerts. It was alleged that R1 had used their emergency alert system and staff did not respond. Interview with R1 revealed that on the night of the alleged incident, they fell and activated their alarm. R1 stated that they activated their alarm, but staff did not arrive to their room. Interview with R6 revealed that they too have used their alarm system and staff has failed to respond. However, interviews with four (4) other residents revealed that when they have activated their alarm system, staff has responded. Interviews with all six (6) staff revealed that when residents activate their alarm, staff do respond. LPA’s record review of the facility’s past call system roster showcased that both R1’s and R6’s alerts have all shown to have been arrived and completed. LPA attempted interviews with R2 and R3 but due to their inability to determine the validity of the allegation, LPA terminated the interviews. LPA attempted to interview R9-R11 but they refused to be interviewed.

Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff did not provide required medical attention to a resident. It was alleged that R1 fell from their bed and sustained a cut on their face and staff did not attend to the injury. Interview with R1 revealed that when R1 showed staff the cut they sustained, staff did help by applying medical dressing on the wound.

Based on interview with R1 that staff did help attend to their wound, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff did not properly maintain a resident's room. It was alleged that when R1 sustained an injury resulting in their bedroom floor needing to be cleaned, the staff did not clean their room until the morning after. Interview with R1 revealed that the day of the alleged incident, they left the facility later in the morning and returned at around 10:00 AM. Upon their return, R1 mentioned that their bedroom floor had been cleaned including where the injury had occurred. Interview with six (6) residents revealed that staff clean their room daily. Interview with all six (6) staff revealed that every day the residents’ rooms are cleaned. S5 and S6 stated that not only are the rooms cleaned daily but Tuesdays and Thursdays are when deep cleaning of the residents’ rooms are performed. While conducting the physical plant tour, LPA witnessed multiple staff members throughout the facility cleaning resident’s rooms. LPA conducted random room checks where they witnessed the residents’ rooms to be clean and properly maintained.

(Continue to LIC 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250414152217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING	FACILITY NUMBER: 197610442
	VISIT DATE: 05/12/2025

NARRATIVE

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Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was provided to the Executive Director.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC9099 (FAS) - (06/04)

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