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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:21:43 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/27/2025 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20250527104046
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: 175DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Angela Smith- Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not maintain the facility in a clean, safe, sanitary condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived, was greeted by the receptionist, and met with the Executive Director, explaining the reason for the visit. LPA requested copies of pertinent information which includes LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations.

Allegation: Staff did not maintain the facility in a clean, safe, sanitary condition
The complainant alleged that there is always feces on the toilets in the facility. LPA conducted phyiscal plant and observed all facility main toilets are clean and in saniatry condition. Interviews with 13 out of 175 residents denied the allegation. Interview with the Executive Director confirmed that staff are providing housekeeping services daily and weekly and as needed. Based on information obtained the allegation is deemed Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/27/2025 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20250527104046

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: 175DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Angela Smith- Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
3
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5
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8
9
Staff did not properly manage resident’s catheter care.
INVESTIGATION FINDINGS:
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3
4
5
6
7
8
9
10
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12
13
Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegations. LPA arrived, was greeted by the receptionist, and met with the Executive Director, explaining the reason for the visit. LPA requested copies of pertinent information which includes LIC 500 and Resident Roster. LPA conducted a physical plan tour, to ensure health and safety of the residents are protected and are in compliance with Title 22 Regulations.

Allegation: Staff did not properly manage resident’s catheter care.
The complaint alleged that Resident #2 (R2) has a catheter implant that overflows and emits an odor. Interview with Staff #2 (S2) did not deny the allegation. S2 stated that R2 is independent; however, R2 requires assistance with urinary catheter care. S2 also mentioned that facility staff check on R2 every two hours for incontinence and catheter care. The LPA reviewed staff notes and found inconsistencies. S2 stated that R2 had refused staff assistance, stating R2 is independent and capable of managing his or her catheter.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20250527104046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEISURE VALE ASSISTED LIVING
FACILITY NUMBER: 197610442
VISIT DATE: 06/05/2025
NARRATIVE
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S2 was unable to provide documentation, as the staff notes and end-of-shift reports were inconsistent. Based on the information obtained, the allegation is deemed substantiated at this time.

Exit interview conducted, citation issued, appeal rights given and copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20250527104046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE VALE ASSISTED LIVING
FACILITY NUMBER: 197610442
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2025
Section Cited
CCR
87625(B)(3)
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(B)General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
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The Executive Director will provide in-service staff training to ensure staff notes are complete and consistent. In addition to developing incontinence care plan and a catheter care plan for Resident 2 by the POC date
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Based on interviews and record reviews, the facility staff did not properly manage resident’s catheter care. This poses a potential 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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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