197610442-12-9-2025-31-AS-NMAN-DPFVEN-20251217152237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 12/09/2025
Date Signed: 12/09/2025 04:03:45 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
07/08/2025 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250708081539

FACILITY NAME:	LEISURE VALE ASSISTED LIVING		FACILITY NUMBER:	197610442
ADMINISTRATOR:	ANGELA SMITH		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS STREET		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 164	DATE:	12/09/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Nilda Mercado, Administrative Services & Coordinator (ASC) Executive Director, Stephanie Oden		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff yell at residents
Staff are mismanaging resident's medications
Staff do not ensure residents are wearing adequate clothing
Staff do not safeguard resident's personal belongings
Staff open mail without resident's consent
Staff do not provide resident's adequate food service
Staff do not follow resident's activities schedule
Staff are not able to communicate with resident's due to language barrier

INVESTIGATION FINDINGS:

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At 10:30am Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver findings of the above noted allegations. LPA met with Nilda Mercado, Administrative Services Coordinator (ASC) Executive Director, Stephanie Oden and explained the reason for the visit.

During initial visit on 07/15/2025 At 10:15a.m., LPA and ASC conducted a physical plant walk-through. Between 11:00a.m. – 12:45p.m., LPA interviewed six (06) out of one hundred and seventy-four (174) residents. At approximately 2:00p.m. LPA interviewed Director of Culinary, Administrative Services Coordinator (ASC) and asked questions relevant to the investigation. LPA request copies of the activities calendar, residents package log, menu and other pertinent documents.

Prior to this visit on 10/23/2025 LPA, Alvizar-Ettima reviewed records and other documentation obtained
Cont. on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

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 5

Control Number 31-AS-20250708081539

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: 12/09/2025

NARRATIVE

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Cont. from LIC9099
during the initial visit. Records included but were not limited to staff training information, residents’ medication administration records, activity calendar and inventory records of residents’ personal belongings. LPA interviewed eleven (11) additional residents including resident#1 (R1) via-phone. On 12/08/2025 LPA, Alvizar-Ettima interviewed Staff #1- #4 (S1- S4) via-phone and requested additional clarification to complete the investigation.

During this visit at 10:50a.m. LPA and ASC conducted a physical plan tour and delivered findings.

1.) Staff yell at residents
It was alleged that non kitchen workers yell at hungry residents to go away. During interview with resident #1 (R1) indicated that they have not seen staff yelling at residents. Interview with additional residents consistently stated staff are respectful and do not yell at residents. Resident #12 indicated that the services are excellent at this facility. Interviews with the Director of Culinary and ASC revealed no complaints of staff yelling at residents. Other staff reported that they are always present during meal service and have not observed staff telling at hungry residents to go away. LPA did not observe staff yelling during the visits.

Based on interviews, observations, and records review, there is insufficient evidence to prove or disprove the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED.

2.) Staff are mismanaging resident's medications
It was alleged that unlicensed staff distribute sleeping pills and other medication at dinner time. Interview with R1 revealed medications as prescribed are provided and had no idea of sleeping pills being distributed at dinner. Staff revealed that all Med-Tech’s are trained at administering medications at designated times. Interview with additional residents confirmed the same practice. Resident #2 (R2) indicated that they take sleeping pills and med-tech always gives them to R2 at bedtime in their room. ASC reported that all Med – Tech staff are trained and certified to administer medications. A review of facility training records verified staff competency requirements. Interviews with staff indicated that medication distribution occurs according to policy and Med-Tech staff distribute medications in the dining room only when appropriate. A review of R2’s medication records showed no discrepancies and confirmed the information that R2 provided. There were no prior complaints regarding medication errors.
Cont. on LIC9099-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20250708081539

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: 12/09/2025

NARRATIVE

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Cont. from LIC9099-C

Based on interviews, observations, and records review, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED.

3.) Staff do not ensure residents are provided adequate clothing
It was alleged that residents are often in pajamas in the common areas. Interview with R1 stated residents are provided with choices and may wear pajamas if they choose. Interviews with all additional residents revealed no concerns about clothing availability. ASC reported no prior complaints and stated staff redirect residents if they attempt to enter the dining room without proper attire. S1 confirmed the information provided by ASC. No observations during the visit indicated that residents lacked adequate clothing.

Based on interviews and observations, there is insufficient information to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED.

4.) Staff do not safeguard resident's personal belongings

It was alleged residents’ room door locks are a missing key and belongings are not secure. Interview with R1 stated they have not experienced theft and that staff assist residents in safeguarding personal items. Interviews with additional residents indicated that staff do safeguard their personal belongings and had no concerns. ASC reported that when residents misplace a key, staff issue a replacement key after confirming identification. Staff interviews confirmed that staff follow facility protocol for key replacement. A review of residents’ personal inventory records and other documents did not reveal any information to verify the allegation.

Based on interviews, observations, and records review, there is insufficient evidence to support the allegation. The allegation is deemed UNSUBSTANTIATED.

5.) Staff open mail without residents’ consent
It was alleged that packages mailed to resident(s) go missing or are opened by staff.
Interview with R1 stated they receive the packages mailed to them. Interviews with additional residents indicated no concern about open or missing packages. R12 reported that staff are strict about properly
Cont. on LIC9099-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20250708081539

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: 12/09/2025

NARRATIVE

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Cont. from LIC9099-C

logging packages, not opening them. ASC confirmed that packages are logged and may only be opened by the resident identified on the package. Staff explained that FedEx/USPS/UPS packages are delivered directly

Based on interviews, observations, and records review, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED.

6.) Staff do not provide residents with adequate food service
It was alleged that burgers served at dinner time are lukewarm. Interview with R1 reported that food is prepared fresh and heated appropriately. Interviews with additional residents reported no concerns about food service. Interview with R16 described food quality as “excellent”. ASC and the Director of Culinary confirm no prior complaints were received about food being cold or not held on a warmer, as staff prepare meals per order and within reasonable time. Observations during the visit showed proper food handling procedures.

Based on interviews, observations, and records review, there is insufficient evidence to support the allegation. The allegation is deemed UNSUBSTANTIATED.

7.) Staff do not follow resident's activities schedule
It was alleged that Bingo is “often unscheduled or canceled.” Interview with R1 indicated Bingo continues as scheduled. Interviews with additional residents stated they had no concerns regarding activity cancellations. ASC stated that Bingo is posted on the monthly calendar and is conducted regularly unless otherwise noted. S1 interview collaborated with ASC and indicated that Bingo is the most popular and requested activity in the facility. A review of activity schedule verified the information revealed by staff. No evidence was obtained showing inconsistency or cancelation of activities.

Based on interviews, observations, and record review, the allegation is deemed UNSUBSTANTIATED.

8.) Staff are not able to communicate with resident's due to language barriers
Cont. on LIC9099-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20250708081539

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: 12/09/2025

NARRATIVE

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Cont. from LIC9099-C

It was alleged staff “pretend to not speak English” or cannot assist residents. Interview with R1 indicated staff communicate effectively, assist residents and can call for Emergency Assistance as needed. Interviews with
additional residents stated they have no concerns regarding communication. ASC reported no prior complaints and stated bilingual staff are available. Interviews with other staff confirmed they can communicate with residents in English and seek assistance from another staff member when needed. No credible evidence was found indicating staff are unable to communicate with residents.

Based on interviews and observations, the allegation is deemed UNSUBSTANTIATED.

No immediate health and safety issues were observed during the visit. No citations issued.

Exit interview was conducted and copy of was provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC9099 (FAS) - (06/04)

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