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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 05/30/2025
Date Signed: 06/10/2025 11:17:19 AM

Substantiated


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
07/10/2024 and conducted by Evaluator Antonia Alvizar-Ettima
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240710101309
FACILITY NAME:LEISURE GROVE, LLCFACILITY NUMBER:
197610442
ADMINISTRATOR:MAYA MNOYANFACILITY TYPE:
740
ADDRESS:413 E. CYPRESS STREETTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 173DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Angela SmithTIME COMPLETED:
10:04 AM
ALLEGATION(S):
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Staff failed to provide emergenvy medical servies in timely manner
INVESTIGATION FINDINGS:
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This is amended copy of the report previously issue on 5/30/25 the document was amended to make the corrections. This is the addendum of the investigation report previously issued on 07/10/24.
Licensing Program Analyst (LPA) Anotonia Alvizar-Ettima conducted an unannounced visit for the above noted allegation. LPA met with Administrator and explained the reason for the visit.

The investigation of the above allegation was initiated by the LPA Rosaura Valenzuela on 07/10/24 at which time LPA interviewed facility staff and residents. At the time of this visit, LPA Alvizar-Ettima inspected the facility at 10:10a.m. and checked call pendants of the residents present in their rooms. While inspecting residents’ rooms and thereafter at 11:25a.m. LPA Alvizar- Ettima conducted interview with seventeen (17) out of one-hundred and seventy-three (173) residents. At 1:15p.m. LPA requested and reviewed facility records, including, but not limited to R1’s facility files, unusual incident reports,and other documents pertaining to allegation. In addition, at approximately 4:30p.m. LPA Alvizar-Ettima spoke with facility staff assisting R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025
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 5
Control Number 31-AS-20240710101309
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 GROVE, LLC
FACILITY NUMBER: 197610442
VISIT DATE: 05/30/2025
NARRATIVE
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Staff failed to provide emergency medical services in a timely manner

It was reported that on 06/21/24 at approximately 7:00p.m., R1 was vomiting and not feeling well. R1’s roommate called for assistance. R1 had been food poisoned and 911 was not called until 11:00p.m. Staff revealed that on 06/21/24, R1 was taken to their room from the dining room at approximately 7:00p.m., by staff due to appearing tired. Shortly after being placed in the bed, R1 vomited and R1 fell asleep. Staff continued to frequently monitor R1 every 30 - 45 minutes until approximately 10:30p.m., when staff noticed that R1 had vomited. At approximately 11:00p.m., staff assessed R1 and due to having shortness of breath decided to call 911.

A review of records revealed that on 06/21/24 R1 was not feeling well since 7:00p.m.
Between 7:00p.m. to 10:30p.m. staff monitored resident and R1 had vomited at list three (3) times. Overall investigation revealed that although between 7:00p.m. and 10:30p.m. staff had knowledge that R1 was vomiting and feeling weak, they did not call 911 emergency services until 11:20p.m.

Based on interviews, and record review, there is a sufficient information to verify validity of the complaint. Hence the allegation is SUBSTANTIATED at this time.

No other health and safety issues noted at the time of this visit.
Under Title 22, Division 6, Chapter 8 following deficiency was issued and recorded on LIC9099D.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Citations on this Visit Report are Under Appeal!

Control Number 31-AS-20240710101309
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 GROVE, LLC
FACILITY NUMBER: 197610442
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
06/02/2025
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care; (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health….
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The Administrator will in service (focus training) to direct care staff regarding emergency protocol. Administrator will submit a sign in sheet and handouts of topics discussed to LPA via fax by due date.
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This requirement is not met as evidenced by. Licensee did not ensure to provide immediate emergency medical assistance to resident (R1), who appeared to be weak and vomiting. This poses an immediate 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
07/10/2024 and conducted by Evaluator Antonia Alvizar-Ettima
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240710101309

FACILITY NAME:LEISURE GROVE, LLCFACILITY NUMBER:
197610442
ADMINISTRATOR:MAYA MNOYANFACILITY TYPE:
740
ADDRESS:413 E. CYPRESS STREETTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 173DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Angela SmithTIME COMPLETED:
10:04 AM
ALLEGATION(S):
1
2
3
4
5
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8
9
Facility staff did not respond in a timely manner to resident's call pendant
INVESTIGATION FINDINGS:
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 This is the addendum of the investigation report previously issued on 07/10/24.
Licensing Program Analyst (LPA) Anotonia Alvizar-Ettima conducted an unannounced visit for the above noted allegations. LPA met with Administrator and explained the reason for the visit.

The investigation of the above allegations was initiated by the LPA Rosaura Valenzuela on 07/10/24 at which time LPA interviewed facility staff and residents. At the time of this visit, LPA Alvizar-Ettima inspected the facility at 10:10a.m. and checked call pendants of the residents present in their rooms. While inspecting residents’ rooms and thereafter at 11:25a.m. LPA Alvizar- Ettima conducted interview with seventeen (17) out of one-hundred and seventy-three (173) residents. At 1:15p.m. PA requested and reviewed facility records, including, but not limited to R1’s facility files, unusual incident reports, other documents pertaining to allegations. In addition, at approximately 4:30p.m. LPA Alvizar-Ettima spoke with facility staff assisting R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20240710101309
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 GROVE, LLC
FACILITY NUMBER: 197610442
VISIT DATE: 05/30/2025
NARRATIVE
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Facility staff did not respond in a timely manner to resident's call pendant

It was reported that on 06/21/24, staff did not respond in a timely manner to Resident #1 (R1's) call pendant. Staff interviews revealed that neither R1 or R2 pushed the call pendant. Staff indicated that they are responding to the emergency calls within ten (10) to fifteen (15) minutes.
On 07/10/24, LPA Valenzuela was unable to speak with R1 as she was not present at the facility. At the time of this visit LPA Alvizar-Ettima was informed that R1 passed away on 06/22/24. Upon checking ten (10) randomly selected residents’ pendants, LPA noted that staff is responding within fourteen (14) minutes. Residents interviewed during this visit did not address any concerns regarding staff response time to the call pendants.

Based on interviews and records review there is not sufficient validity of the complaint, Thus, this allegation is UNSUBSTANTIATED at this time.

No health and safety issues noted at the time of this visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5