<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 04/20/2021
Date Signed: 04/20/2021 02:46:53 PM



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
10/19/2020 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201019103350
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: 82DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Assistant Administrator Jesse Luera- Mota.TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is being illegally evicted
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The purpose of this report is to deliver the findings from the original complaint dated 10/19/2020.
Initial visit was conducted on 10/26/2020 and included the following:
Licensing Program Analyst (LPA) Glenn Trueman conducted 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 Assistant Administrator Jesse Luera- Mota.
At today's visit at 1:45 PM Assistant Administrator Jesse Luera- Mota was interviewed.
At 2:20 PM Maintenance Staff Saul Blanco was interviewed.
In regards to the allegation Resident is being illegally evicted, interviews with Administrator revealed that Resident 1 had returned and was welcomed back after rehabbing at a nursing home and had not said she would be evicted. Resident 1 stated she had come back and that eviction was not an issue.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
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 3
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
10/19/2020 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201019103350

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: 82DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Assistant Administrator Jesse Luera- Mota.TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Air conditioner in resident's room is giving off heavy fumes
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
In regards to the allegation Air conditioner in resident's room is giving off heavy fumes, based on interview conducted with Maintenance Staff the air condition unit in Resident 1's room contained dirty filters and needed cleaning.
Said that he got to the room and could smell the strong odor in the hallway.
Once the filters were replaced everything operated properly.
Resident 1 was interviewed and stated the unit was giving off heavy fumes with a strong odor.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Deficiency cited under California Code of Regulations Title 22
Hardcopy was provided via email for signature. Appeal Rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20201019103350
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility to ensure that facility be clean, safe, sanitary and in good repair at all times by POC due date.
Facility replaced filters and air conditioning unit operated properly.

Deficiency cleared.
8
9
10
11
12
13
14
Based on observation and interviews, the licensee failed to ensure that the facility is clean, safe, sanitary and in good repair at all times with air conditioning unit in Resident 1's room having strong odor smelled into the hallway with filters having to be replaced which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3