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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:15:08 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
04/17/2024 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20240417123440
FACILITY NAME:LEISURE GROVE, LLCFACILITY NUMBER:
197610442
ADMINISTRATOR:KHODORKOVSKY, AARONFACILITY TYPE:
740
ADDRESS:413 E. CYPRESS STREETTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 149DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Brandy Rangel, Assistant AdministratorTIME COMPLETED:
02:13 PM
ALLEGATION(S):
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Due to lack of supervision, resident was able to leave the facility unassisted
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Assistant Administrator Brandy Rangel and explained the reason for the visit.

It was reported that due to lack of supervision, Resident #1 (R1) was able to leave the facility unassisted. On 04/18/2024, between 11:45am and 12:10pm, staff interviews were initiated. Interviews revealed that R1 arrived to the faciility on 4/16/2024 at approviately 2:30pm and left the community at approximately 4:30pm the same day . R1 has not returned to the facility to pick up their belongings or to sleep there and never signed the admissions agreement. They left the facility before the paper work was finalized. Between 12:15pm and 12:45pm, LPA reviewed facility records. Records confirmed what staff had told LPA. In addition, records revealed that R1 is ambulatory and is able to leave the facility unassisted. The facility is not locked down.
Continue on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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-20240417123440
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: 04/18/2024
NARRATIVE
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Based on interviews and records review, there is sufficient information to not support this allegation. Therefore, 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
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