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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 04/26/2021
Date Signed: 04/26/2021 11:39:00 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:JESSE MOTAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 74DATE:
04/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jesse MotaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Nicole Spencer conducted a case management visit attached to a complaint visit (Control #:28-AS-20210128145900) in which LPA observed an A/C wall unit in disrepair in room #62. LPA discussed the purpose of today's case management visit with the administrator. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Jesse Mota, the facility administrator.

On 2/8/2021, LPA Spencer took a physical plant tour of the facility. In room 62, LPA observed that the A/C and heating unit was in disrepair, unplugged, and taped to prevent use. A small space heater was observed and the administrator stated that this was the temporary space heater until the A/C company could fix the wall heater. The administrator stated that as of today, 4/26/2021, the unit has not yet been replaced.

The following deficiency was observed and cited per California Code of Regulations, Title 22, Division 6 on the attached 809-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to the administrator.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2021
Section Cited

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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by...
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Based on observations and interviews, the licensee did not ensure that the individual heating unit in room 62 was in good repair. This poses a potential safety risk of persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2021
LIC809 (FAS) - (06/04)
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