197610442-11-14-2025-31-AS-TAGD-DQDRGM-20260116120100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 11/14/2025
Date Signed: 11/14/2025 04:20:28 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
08/14/2025 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20250814112828

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: 166	DATE:	11/14/2025
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Stephanie Oden		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not assist resident with mobility needs in a timely manner.
Staff did not dispense medication to resident as prescribed.
Staff did not provide resident with adequate fluids.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with administrator, Stephanie Oden, and explained the reason for the visit.

---Staff did not assist resident with mobility needs in a timely manner.

It was alleged that facility staff leave Resident #1 (R1) lying in bed all day and do not help R1 get out of bed. To investigate the allegation, on 08/15/2025, LPA Antonia Alvizar-Ettima requested documents at 10:30 a.m. and conducted a physical plant tour. On 10/24/2025, LPA Duguma requested documents at around 10:00a.m. LPA also interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. The Physician’s Report dated one (01) year prior to the incident states R1 is ambulatory.

(CONT. LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250814112828

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: 11/14/2025

NARRATIVE

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Hospital discharge records do not indicate mobility status, only that R1 needs to be standing or sitting upright when taking medication. R1’s Service Plan states daily frequency for standby transfer assistance and care team supports R1 with safe ambulation, mobility and repositioning. A review of the staff personnel records and schedule shows that facility has eight (08) caregivers per shift providing care and supervision to eight (08) residents. During interviews with staff, all staff stated R1 was checked on frequently and assisted in and out of bed as needed. Staff added R1 was never without care and supervision. During interviews with residents, all residents stated they are checked on often and those that need transfers confirmed they receive assistance. LPA was unable to interview R1.

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

---Staff did not dispense medication to resident as prescribed.

It was alleged that staff have not been giving R1 lidocaine medication that R1 should be receiving before meals. To investigate the allegation, on 08/15/2025, LPA Antonia Alvizar-Ettima requested documents at 10:30 a.m. and conducted a physical plant tour. On 10/24/2025, LPA Duguma conducted a physical plant tour and requested documents at around 10:00a.m. LPA also interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. A review of the Medication Administration Records shows medications were not given as it was suspended from 08/11/2025 to 08/16/2025 per physician's orders. During interviews with staff, Staff #1 stated the medication was withheld by the physician and R1 had a liquid pain killer as a temporary substitute. All other staff stated residents are given their medications as prescribed. During interviews with residents, all residents stated they receive their medications as prescribed. LPA was unable to interview R1.

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

(CONT. on LIC9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20250814112828

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: 11/14/2025

NARRATIVE

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---Staff did not provide resident with adequate fluids.

It was alleged that R1 is not given enough water. To investigate the allegation, on 08/15/2025, LPA Antonia Alvizar-Ettima requested documents at 10:30 a.m. and conducted a physical plant tour. On 10/24/2025, LPA Duguma conducted a physical plant tour and requested documents at around 10:00a.m. LPA also interviewed seventeen (17) residents and four (04) staff from 11:30a.m. – 2:30p.m. A review of most recent Hospital Discharge documents does not indicate resident suffered from dehydration. There are also no incident reports filed that would indicate R1 suffered from dehydration around the time in question. During the physical plant tour, LPA observed drinking water available for residents and in resident rooms. During interviews with staff, all staff stated they make water readily available for all residents and check to make sure all residents are drinking water. During interviews with residents, all residents stated they feel they have easy access to drinking water and that they are checked on often. LPA was unable to interview R1.

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

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

LIC9099 (FAS) - (06/04)

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