191290642-6-24-2020-31-AS-MVAO-BS6PPQ-20200804112952

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 06/24/2020
Date Signed: 06/24/2020 08:53:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2020 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20200526161342

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	POLITA BARNES		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 89	DATE:	06/24/2020
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Cynthia Valdez		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not assisting resident with medication as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Pitz initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with staff.
As part of this investigation LPA conducted a video inspection of the facility's medication room and Resident 1's (R1's) Medication Assistance Record on 5/26/20. LPA also interviewed two staff members on 5/26/20 and one resident on 6/5/20.
Allegation #1, that "Facility is not assisting resident with medication as prescribed," has been unsubstantiated based on the interviews conducted and observations made. LPA did not observe any deficiencies while reviewing medication son 5/26/20, and R1 indicated that the change in medications that prompted this complaint was ordered by their doctor shortly before they refused to cooperate with the investigation.

A telephonic exit interview was conducted with staff, and a hard copy was provided via email for signature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 5964342
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2020

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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