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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610442
Report Date: 10/25/2024
Date Signed: 10/25/2024 03:30:36 PM

Document Has Been Signed on 10/25/2024 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
197610442
ADMINISTRATOR/
DIRECTOR:		MAYA MNOYANFACILITY TYPE:
740
ADDRESS:413 E. CYPRESS STREETTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 199CENSUS: 158DATE:
10/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:39 AM
MET WITH:Angela SmithTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit to this facility to address an incident which allegedly occurred on 10/17/2024. LPA met with Executive Director Angela Smith (ED) and explained the reason for the visit.

It was alleged that Staff #1 (S1) financially abused multiple residents in the facility. According to the ED’s statements, there are currently six (06) residents involved in the alleged abuse of which three (03) filed police reports. ED stated R1 did not report anything to the facility, and only found out about anything the day after S1 was arrested and the police informed them that R1’s debit card was found on S1’s person.

ED added that on 09/25/2024, Resident #2 (R2) discovered possible fraud while attempting to pay their monthly debt obligations. R2 and a representative from the facility went to the bank and confirmed there was possible financial fraud. R2 reported the suspected abuse to the Glendale Police department and a report was filed 09/26/2024.

Facility also disclosed that on 10/05/2024, Resident #3’s (R3) responsible party reported to the facility that they suspected financial fraud and a week later brought a copy of the police detective’s information and police report number to let facility know they filed a report. Similarly, on 10/05/2024 Resident #4 (R4) also discovered that something was wrong when trying to pay their rent and notified the facility about filing a police report and provided the detective’s information and police report number.

(CONT. on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/25/2024
NARRATIVE
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A review of the department’s records revealed that facility did not submit an incident report for the 09/25/2024 incident. During the police department’s investigation, the ED was asked about a seventh potential victim, but after reviewing the facility’s records it was determined that the person was not a current or past resident of the facility. When LPA asked about dollar amounts, the ED stated they are currently unaware as the investigation is ongoing. ED was also asked about any missing credit cards around 08/28/2024 and ED stated nothing was discovered or reported within the past six (06) months.

LPA interviewed four (04) out of six (06) of the alleged victims all of which confirmed some form of financial abuse. LPA was unable to interview the other residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

The ED was informed that the Department may take additional action if deemed necessary.

No other health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2024 03:30 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Abeye Duguma On 10/25/2024 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/26/2024
Section Cited
CCR
87211(a)(2)

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Each licensee shall furnish to the.. agency.. reports…Occurrences…which threaten the welfare,...of residents.. shall be reported within 24 hours...Licensee did not meet the requirement as evidenced by submitting the incident report not until 10/24/2024...As a reminder to the licensee, as a mandated
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Licensee will submit a written letter by the POC due date stating that they have reviewed Title 22 Division 6 Chapter 8 of the CA Code of Regulations 87211 Reporting Requirements in FULL and that going forward will adhere to these regulations.
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reporter…..the administrator… has knowledge of an incident that reasonably appears to be …. financial abuse….a written report shall be sent, or an Internet report... established in Welfare and Institutions Code Section 15658, within two working days.
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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.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Abeye Duguma
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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