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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 08/25/2025
Date Signed: 08/25/2025 03:44:19 PM

Substantiated


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
08/15/2025 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20250815105727
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: 169DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director, Stephanie OdenTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced 10-day complaint visit to this facility at 10 am to investigate the above allegations. LPA met with the executive director and disclosed the reason for the visit.

Staff are mismanaging resident's medication
It was alleged that Resident #1 (R1) frequently doesn’t receive their medication because staff does not have it and medication is not administered as prescribed. To investigate the allegation, LPA Smith interviewed five (05) staff, fifteen (15) residents, and requested documents relevant to the investigation. A review of Resident #1’s (R1) medication records reveal multiply order changes to suppository medication with current change to be administered at 7am and 5pm. Interview with R1 reveal did not receive it or staff are a few hours late in administering suppository. During interviews with staff, two (2) of five (5) staff stated all medications are given as prescribed. Three (3) of five (5) staff state that R1 was
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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 3
Control Number 31-AS-20250815105727
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 VALE ASSISTED LIVING
FACILITY NUMBER: 197610442
VISIT DATE: 08/25/2025
NARRATIVE
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(Cont from 9099)

not administered suppository due to an episode of loose stools and that R1 regularly changes the times they want the medications administered. Interviews with five (5) of fourteen (14) revealed they have not received their medications because their medication is not available and/or they received their medications up to 3 hours late. One (1) of fourteen (14) residents revealed witnessed R1 in pain from not receiving medication. Eight (8) of fourteen (14) residents stated they are given their medications as prescribed.

Based on interviews and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250815105727
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 VALE ASSISTED LIVING
FACILITY NUMBER: 197610442
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2025
Section Cited
CCR
87465(c)(2)
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87465-Incidental Medical & Dental Care (c) If the resident 's physician stated in writing that the resident is able to determine his/her own prescription medications...the licensee shall be permitted to assist resident with self-administration […](2) Once ordered by the physician the medication is given according to the physician's directions.
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The Licensee shall submit in writing to the department by 09/08/25, how they will ensure that medication is order, available, and administered according to doctors order. The licensee shall provide medication training to staff and provide proof that the training was completed.
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This requirement was not met as evidenced by...staff failing to give medication at time prescribed or not at all. This poses an immediate and health and safety 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: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3