197610442-5-13-2026-31-AS-MGFS-DUFLVL-20260526090541

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610442
Report Date: 05/13/2026
Date Signed: 05/13/2026 10:09:34 AM

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
10/03/2025 and conducted by Evaluator Leslie Ngo-Castaneda

COMPLAINT CONTROL NUMBER: 31-AS-20251003161950

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: 172	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Nina Mercado- administration coordinator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff discriminates against a resident in care.
Staff did not respond to a resident's call light.
Staff do not treat resident with dignity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent complaint visit to deliver findings on the above-mentioned allegations. LPA met with administration coordinator, Nida Mercado, and explained the reason for the visit.

The investigation consisted of the following:

On 10/13/2025 at 10:30 a.m., Licensing Program Analyst (LPA), Evelin Rios, conducted an initial, unannounced complaint visit. LPA met with Stephanie Oden the Administrator and explained the reason for the visit. LPA requested the resident and staff roster. At approximately 10:49 a.m., LPA initiated the physical plant tour to ensure the health and safety of the residents in care. LPA conducted call button test and reviewed a call button log in the facility’s computer. Between 11:00 a.m. and 2:00 p.m., LPA interviewed nine (9) residents, one (1) of whom declined to be interviewed, and six (6) staff members from 2:00 p.m. to 3:30 p.m. Continue to LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

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-20251003161950

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: 05/13/2026

NARRATIVE

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(Continued from LIC9099)

LPA conducted interviews with an additional ten (10) residents and three (3) staff members. On 10/16/2026 LPA Rios conducted an interview with an additional resident. On 05/06/2026 LPA Rios requested and obtained copies of R1’s documents such as Physician’s Report (LIC602), and Resident Appraisal from the facility.

The investigation revealed the following:

Regarding the allegation, staff discriminate against a resident in care. It is alleged that staff treated a resident differently from other residents. LPA’s interview with sixteen (16) out of twenty (20) residents stated they had not been discriminated against by staff. Three (3) residents stated they may have experienced discrimination at some point in the past by staff but were not sure when. They reported they don’t feel that way now. One (1) resident stated they felt staff were friendlier toward other residents than toward them. The residents could not provide a timeframe, identify who was involved, or describe any specific discriminatory actions. Interviews with nine (9) staff denied any discriminatory conduct and stated they have not witnessed residents being discriminated against by other staff. Staff also reported not receiving complaints from residents related to discrimination.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

Regarding the allegation, staff do not treat a resident with dignity. It is alleged staff ridiculed resident in care. Interviews with seventeen (17) out of twenty (20) residents stated they had not been made fun of by staff. Two (2) residents stated they believed staff talk among themselves and felt staff laugh at them but could not hear what is said. Interviews with nine (9) staff indicated they have not made jokes about residents nor witnessed other staff making jokes or inappropriate comments toward residents. Staff reported they feel comfortable bringing any concerns to management or addressing the issue directly with the staff involved.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

Continue to LIC 9099-C

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20251003161950

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: 05/13/2026

NARRATIVE

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Regarding the allegation, staff did not respond to a resident's call light. It is alleged staff did not respond to resident’s call light when resident needed assistance to the bathroom. Interviews with sixteen (16) residents revealed that they had pushed the call button/call light for assistance. Three (3) of which stated they were independent and did not need to call for assistance. Seven (7) out of the sixteen (16) residents stated that had called for assistance reported call-light response times were fine, while three (3) out of the sixteen (16) reported to have waited 1-3 hours and five (6) out of the sixteen (16) reported wait times varied with the longest being 30 minutes and it depended on the shift but also reported staff provided a reason for a delay on response time. Interviews with nine (9) staff reported that they typically respond within 5 minutes, stating they go straight to the room and turn off the call-light button, unless they are already assisting another resident. Staff also state they communicate with other staff if they cannot make it to the room so that someone else can assist the residents. LPA conducted a test of four (4) call buttons in 4 resident rooms and staff responded within five minutes or less. On 10/13/26, LPA reviewed the facility’s call light log and observed two rooms where call lights were tested earlier to which staff responded, continued to show the calls as active. According to the receptionist, staff may forget to turn off the call light after assisting someone or the call light might be on in error.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

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