197610442-9-5-2024-31-AS-NMAN-D9ARBW-20240920125324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 09/05/2024
Date Signed: 09/05/2024 02:36:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/29/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240529142935

FACILITY NAME:	LEISURE GROVE, LLC		FACILITY NUMBER:	197610442
ADMINISTRATOR:	MAYA MNOYAN		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS STREET		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS:	DATE:	09/05/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident eloping from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above allegation. LPA met with the assistant administrator, Brandy Rangel, and explained the reason for the visit.

---Staff did not provide adequate supervision resulting in resident eloping from facility.

It was alleged that Resident #1 (R1) was found lying on a sidewalk a short distance from the facility. To investigate the allegation, on 05/29/2024 LPA Rosaura Valenzuela requested pertinent documents. On 09/05/2024, LPA interviewed two (02) staff from 11:00 AM – 12:00 PM. A review of the R1’s Physician’s Report states that R1 can leave the facility unassisted. The Needs and Service Plan indicates that R1 is not a wandering and elopement risk, does not require assistance and is independent.

(CONT on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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-20240529142935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE GROVE, LLC	FACILITY NUMBER: 197610442
	VISIT DATE: 09/05/2024

NARRATIVE

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During interviews with staff, all staff stated that it was an isolated incident, R1 was walking uphill and became exhausted, R1 is independent and remains able to leave and return unassisted.

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

No health and safety hazards were noted during the visit.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC9099 (FAS) - (06/04)

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