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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 04/02/2021
Date Signed: 04/06/2021 08:38:19 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
12/31/2020 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201231112821
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:POLITA BARNESFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 71DATE:
04/02/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jesse LoeraTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident's phone line is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted another complaint visit 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 telephonically with Assistant Administrator, Jesse Loera.

The investigation consisted of the following : interview(s) with Administrator, Staff #1- Staff #3, and Resident #1 - Resident #9. Administrator and staff interviewed, denied the allegations. They stated that most of the residents have personal cell phones, or they can use the telephones provided in the hallway(s). Staff stated that some residents do have phone lines in their room(s) for internet usage. Staff stated that if a resident's phone line isn't working, resident(s) just have to notify staff, and it will be repaired for them.

Residents interviewed stated that they do not have any issues with the phone lines. They stated that if something in their room isn't working, they just have to notify staff, and staff will take care of it. They stated that staff take care of repairs promptly.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021
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 2
Control Number 28-AS-20201231112821
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: 04/02/2021
NARRATIVE
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Based on LPA's observations and interviews, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted via telephone with the Assistant Administrator and a hardcopy was provided via email for signature. Signatures on hardcopy.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2