191290642-8-18-2020-28-AS-MVAO-BTQPXT-20200923114251

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/17/2020
Date Signed: 08/18/2020 09:51:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200714165531

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: 88	DATE:	08/17/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Assistant Administrator Jesse Luera- Mota		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff poisoned resident's food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's complaint investigation was conducted via tele-video (Facetime) with Assistant Administrator Jesse Luera- Mota.
Initial visit 7/21/20 consisted of the following: Assistant Administrator Jesse Luera- Mota was interviewed at 1:45 PM.
At today's visit at 1:45 PM Lead Chef Jose Gradilla was interviewed. At 2:05 PM tour of the kitchen and food supply were conducted.
Food supply contained a surplus and well balanced supply of chicken, meat, fish, veggie patties, egg roils, ravioli, ham, brisket, vegetables, milk and eggs and deserts.
At 2:05 PM to 2:45 PM Resident's 1-7 were interviewed.
In regards to the allegation Staff poisoned resident's food, interview conducted with Resident 1 who stated that she has never found any material evidence in food that would show that the food is being poisoned.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

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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Control Number 28-AS-20200714165531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 08/17/2020

NARRATIVE

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Resident's 2-7 stated the food was of good quality and temperature with the option of having 2nds.
All stated they have never found any objects in their food and never found anything poisonous in the food. Interview with head chef who has been there 30 years who revealed that he has always followed all the rules and would never put anything in the food.
Stated that only Resident 1 has made that complaint, but partakes in the meals and at times has 2nds.
Interview with Administrator who stated there have been no other complaints from other residents and it has been an ongoing issue with Resident 1 who has refused a psych appointment.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is found to be: Unsubstantiated.

A telephonic exit interview was conducted with Assistant Administrator Jesse Luera- Mota, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

LIC9099 (FAS) - (06/04)

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