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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 06/10/2025
Date Signed: 06/10/2025 02:19:27 PM

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
06/09/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20250609142241
FACILITY NAME:LEISURE VALE ASSISTED LIVINGFACILITY NUMBER:
197610442
ADMINISTRATOR:ANGELA SMITHFACILITY TYPE:
740
ADDRESS:413 E. CYPRESS STREETTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 174DATE:
06/10/2025
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Angela Smith- Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility staff did not seek timely medical attention for resident in care.
INVESTIGATION FINDINGS:
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At 10:10 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit for the above allegation. LPA was greeted by the receptionist, and met with the Executive Director (ED) and explained the reason for the visit.

At 10:20 AM, LPA requested resident and staff roster. At approximately 10:30 AM, LPA conducted a physical plant tour of the facility. At 10:45 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, and etc., relevant to the investigation. Between 10:55 AM – 1:30 PM, LPA interviewed ED, Wellness Director (WD), Admission Cordinator (AC), Engagement Director, and seventeen (17) out of twenty one (21) residents who were avaliable.

Continue on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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 2
Control Number 31-AS-20250609142241
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: 06/10/2025
NARRATIVE
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Facility staff did not seek timely medical attention for resident in care.
It is alleged that on 06/05/2025, the facility staff sent Resident #1 to the senior-program with constipation and neck pain and did not provide medical attention. To investigate this allegation LPA conducted an interview with the ED who informed LPA that R1 did not report any constipation or neck pain to the facility staff on 06/05/2025. Furthermore, LPA was informed that on 02/27/2025, R1 did report constipation issue and the facility staff immediately informed the Primary Care Physician and hospice. An immediate medical attention was provided to R1 through hospice agency. Interview with the WD and Engagement Director confirmed the information provided by ED. sixteen (16) residents interviewed express no concerns regarding the above allegation. Lastly, interview with R1 revealed that no information was provided to facility staff on 06/05/2025 and LPA was informed that once R1 went to the senior program R1 experienced discomfort and constipation. Therefore, based on information gathered during today's visit, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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 2