197610442-6-2-2026-31-AS-TAGD-DVN2KH-20260703172758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 06/02/2026
Date Signed: 06/02/2026 12:30:54 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
04/16/2026 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260416151237

FACILITY NAME:	LEISURE VALE ASSISTED LIVING		FACILITY NUMBER:	197610442
ADMINISTRATOR:	STEPHANIE ODEN		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS STREET		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 164	DATE:	06/02/2026
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Stephanie Ogden, Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff do not meet resident's incontinence care needs in a timely manner, resulting in resident sustaining multiple pressure injuries.
Staff do not assist resident with repositioning
Licensee does not ensure there is enough staff to meet resident's needs in a timely manner
Staff do not follow resident's care plan
Staff do not provide resident with bed prescribed by a physician

INVESTIGATION FINDINGS:

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On 06/02/26, at 8:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Stephanie Ogden, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 04/22/26, LPA Saucedo conducted the initial complaint visit, conducted a physical tour and interviewed residents and staff. On 06/02/26, at 9:50am, LPA Saucedo conducted another physical tour, interviewed additional staff and residents.

LIC 9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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-20260416151237

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: 06/02/2026

NARRATIVE

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Regarding the allegation: Staff do not meet resident's incontinence care needs in a timely manner, resulting in resident sustaining multiple pressure injuries. It is being alleged that resident #1 (R1) waits for an hour or two (2) before a staff comes to help them and they developed pressure injuries. During LPA’s interview with R1, R1 stated, “I don’t get changed often and I am left in soiled diapers waiting for a staff.” LPA asked when do they change you and R1 stated, “only in the morning and before I go to bed.” LPA obtained a copy of incontinence residents and R1 is supposed to be changed four (4) times a day and during the nocturnal shift (NOC). During LPA’s physical tour, R1 was observed spending most of their day out of the facility. LPA conducted another interview with R1 on 05/12/26 and observed them out of their room during incontinence scheduled. When questioned as to why they are not in their bedroom and/or in the facility during the scheduled incontinence changes, R1 stated, “I don’t use the bathroom much so I just decide to stay in my diaper.” LPA asked R1 if they wanted to go to the hospital so they can get re-evaluated for all their concerns, R1 stated to LPA, “they are not going to the doctor, they are doing fine and their wound is doing much better.” LPA did obtain Home Health notes for R1 on 05/04/26 and it was determined that R1 developed a stage 3 wound on their buttocks area on 03/23/26. Furthermore, LPA interviewed one (1) of the Home Health case managers regarding R1 and they stated, “R1 did have a stage 3 in their buttocks area but it is now healed.” Let it be noted, R1’s admission to the facility was on 01/27/26 and was discharged from the health care center on 01/26/26 with no wounds. Furthermore, LPA interviewed three (3) facility staff that confirmed R1 does not like to be touched and refuses to go to the hospital for anything that they have complained about. LPA's interview with the Licensed Vocational Nurse stated, "R1’s wound now looks like a stage 1 and not a stage 3 wound anymore.” Therefore, based on the home health records of wound care and the refusal of R1 to be changed per the incontinence schedule, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time.

LIC 9099C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20260416151237

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: 06/02/2026

NARRATIVE

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Regarding the allegation: Staff do not assist resident with repositioning. It is being alleged that resident #1 (R1) does not often get repositioned in bed so they have constant pain. During LPA’s interview with R1, R1 stated, “they have constant back pain.” LPA asked how often are you repositioned and R1 stated, “it’s not the repositioning it’s the bed that I have. I want an airbed that is on the floor and that has a black machine where I can blow up.” LPA asked how often does staff come and reposition you in bed and R1 stated, “they come and help me with bathing, changing my clothes and place me in my wheelchair.” Let it be noted, R1 is not bedridden and/or bed bound, R1 is non-ambulatory. LPA interviewed three (3) facility staff that confirmed R1 is not complaining about their repositioning they are complaining about back pain and want the same bed they had at their Home Care Center. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Licensee does not ensure there is enough staff to meet resident's needs in a timely manner. It is being alleged that there is not enough staff in the facility, and the staff turnover is very high. LPA interviewed four (4) caregivers that have been there for a few years and the four (4) caregivers confirmed they are assigned certain rooms and residents and they do their best to accommodate the residents but it depends also what they need help with. In addition, they have an outside agency that is used for extra help. During LPA’s physical tour on multiple occasions 04/22/26, 05/12/26, 05/19/26, LPA observed several caregivers, housekeepers and medical technicians helping different residents. LPA observed R1, not to be in their room but outside of the facility on these different dates. LPA asked R1 what is their need that is not being met and R1 stated to LPA, “when I need changing in the morning they do not come fast enough for me.” LPA stated to R1, you do have a caregiver assigned to you and a housekeeper and I have seen the outside agency staff come help you when you have requested help and R1 stated, “yes, they’ll send the outside help to come help me if the facility staff is not available.” Furthermore, LPA interviewed eleven (11) other residents that confirm there is an outside agency that comes to help the facility and that facility staff is also meeting their needs. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time.

LIC 9099C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20260416151237

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: 06/02/2026

NARRATIVE

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Regarding the allegation: Staff do not follow resident's care plan. It is being alleged that resident #1 (R1)’s care plan is not being followed. During LPA’s file review of R1, it was determined that R1 needs help with several ADL’s-Activities of Daily Living such as bathing, dressing, toileting, transfers and repositioning. LPA obtained R1’s Pre-Placement Appraisal, Medical Assessment, Service Plan, Home Health notes for wound care, R1’s Home Care Center admission record, Incontinence Schedule, Admission Agreement and Identification and Emergency Information. During LPA’s interview with R1, R1 did confirm that they get help with bathing, dressing, toileting, changing clothes and transfers to their wheelchair. LPA asked what about repositioning and R1 stated, “yes, because they use a Hoyer lift to help me, with two (2) staff. In addition, LPA did observe a Hoyer lift in R1’s room. Let it be noted, R1 is alert and can eat and take their prescribed medication on their own. LPA interviewed three (3) facility staff that confirmed R1 does not like to have staff help them throughout the day only when in the morning when they first get up and at night when R1 is getting ready to go to bed. LPA interviewed R1 again and asked R1 if they would go to the hospital so they can get re-evaluated for all their concerns and R1 stated to LPA, “they are not going to the doctor, they are doing fine.” Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff do not provide resident with bed prescribed by a physician. It is being alleged that resident #1 (R1) was told they could have the airbed that their doctor ordered for them, but R1 still does not have that air bed. During LPA’s interview with R1, R1 stated, “they wanted an airbed the same airbed they had at the Health Care Center.” LPA Interviewed a Health Care Center staff whom stated “R1 had a low air loss mattress for back support.” Furthermore, LPA also interviewed two (2) facility staff who stated, “they ordered a new mattress cushion for R1 called Medical Over Lay Mattress which is a therapeutic pad placed over a standard bed to enhance comfort and prevent skin breakdown but R1 is still not happy with the mattress they have ordered and mentioned it again that they wanted the same mattress they had at the Health Care Center. Let it be noted, there was not a bed prescribed by a physician. Therefore, based on the staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

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