197610442-6-28-2024-31-AS-NMAN-D9WMHU-20241010093807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 06/28/2024
Date Signed: 06/28/2024 02:45:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
06/24/2024 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20240624134254

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: 143	DATE:	06/28/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Brandy Rangel		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not prevent an altercation between residents

INVESTIGATION FINDINGS:

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At 9:45 a.m. on 06/28/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the assistant administrator and disclosed the reason for the visit.

To investigate the allegations above, LPA toured the facility at 10:00 a.m., interviewed three (03) residents between 10:20 a.m. and 10:45 a.m., four (04) staff between 10:10 a.m. and 11:45 a.m., and conducted a records review of pertinent records including but not limited to admission agreements, medical assessments, and service plans at 12:00 p.m.

Regarding the allegation “Staff did not prevent an altercation between residents” it was alleged staff did not intervene to prevent a physical altercation between Resident #1 (R1) and Resident #2 (R2) in the dining room on 06/22/2024.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

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-20240624134254

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEISURE GROVE, LLC	FACILITY NUMBER: 197610442
	VISIT DATE: 06/28/2024

NARRATIVE

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Interview with R1 at 10:20 a.m. today revealed R1 and R2 were arguing and R2 lightly hit R1 in the arm five (05) to six (06) times. R2 then called R1 a derogatory slur and R1 slapped R2. R1 stated they had not fought before and no longer intend to fight. R2 “always wants to start stuff” with R1. R1 also admitted they are confused, struggle with mental stability, and take medication for the problem. R1 could not recall if staff intervened. Interview with R2 at 10:35 a.m. today revealed they did call R1 a derogatory slur and R1 slapped R2. R2’s partner Resident #3 (R3) called the police. R2 stated R1 was always in the hallways “looking for a fight”. R2 also stated no staff intervened and they do not feel safe living at the facility. The assistant administrator held a meeting with R1 and R2 the following day and instructed the two to stay away from one another. Interview with Staff #1 (S1) at 10:45 a.m. today revealed they were in the TV room when they had heard R1 and R2 arguing in the dining room. S1 ran over and saw R1 with their hands on R2’s wheelchair and R1’s face very near R2’s face. S1 put their body in between R1 and R2. R1 then slapped R2, and R2 slapped R1. S1 separated the two residents afterwards. Interview with Staff #2 (S2) at 10:10 a.m. today revealed staff are trained to place their hands and arms between residents to break up fights. Interview with the assistant administrator revealed R2 had a history of using derogatory slurs and starting fights. During the meeting between R1 and R2 and the assistant administrator on 06/23/24, the police’s instructions for the two to stay away from each other were reiterated. The assistant administrator also stated the facility has scheduled staff training with their consultant group for all residents with known behavioral issues. It was stated that the service plans for R1 and R2 were not updated to address their arguments and altercations. Record review at 12:00 p.m. today revealed R2’s service plan noted the facility “will observe for mood changes, agitation... signs of anxiety”. R1’s service plan noted the facility “will observe client daily for mood changes, apathy, aggression, agitation". Based on interviews and record review, facility staff did not intervene in time to prevent an altercation between R1 and R2. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 9099-D page.

No immediate health and safety risks were observed during today's visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20240624134254

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEISURE GROVE, LLC	FACILITY NUMBER: 197610442
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 07/26/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations This requirement is not met as evidenced by:	1 2 3 4 5 6 7	In addition to scheduling staff trainings with a consultant for residents with challenging behaviors, the licensee has agreed to update the service plans of Resident #1 (R1) and Resident #2 (R2) with instructions for staff intervention.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above in two (02) out of one hundred forty three (143) residents which poses a potential Health, Safety, or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

LIC9099 (FAS) - (06/04)

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