191290642-4-20-2021-28-AS-FFIS-C2KUGC-20210430153408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 04/19/2021
Date Signed: 04/20/2021 03:02:28 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
03/27/2019 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20190327091300

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: 71	DATE:	04/19/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Jesse Mota		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff failed to provide adequate supervision resulting in a resident sustaining injuries due to multiple falls

INVESTIGATION FINDINGS:

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***This report supersedes LIC 9099 Licensing report dated 3/04/20 to include immediate civil penalties not issued on that date. LPA Villalobos met with Administrator Jesse Mota, no changes were made to the findings and details of the original report***

This is an amendment to the report dated 11/15/19 due to LPA did not indicate what injuries resident #1 sustained a injury due to the falls in the facility. However the findings remain the same as follows:

A complaint was received in our Department on 3/27/19. IB took on this assignment as a full investigation.
During this investigation Investigator Dennis Douglas reviewed medical records of (R#1) conducted interviews Reviewed previous incident reports,and reviewed Hospital medical records of resident #1.
The investigation revealed the following:
Resident #1 who we will refer as (R#1) was admitted to the facility on 9/27/17. R#1 fell in the facility on the following dates: 10/14/17, 11/22/17, 6/2/18 and 3/18/19. R#1 was identified as a fall risk by the facility...

Contined on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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-20190327091300

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: 04/19/2021

NARRATIVE

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***This report supersedes LIC 9099 Licensing report dated 3/4/20***

;however she continued to have incidents of falling at the facility. There was no plan put in place by the facility to prevent R#1 from having falls. R#1 was moved to another room at the facility and sustained a fall after she was moved to another room. R#1 moved out of the facility on 3/20/19. R#1 sustained a femoral neck fracture (hip).
Based on the observations and interviews which were conducted and record review(s),LPA agrees with the Investigator and finds that the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D and an immediate civil penalty will be assessed

Immediate Civil Penalties are being issued on 4/19/21 in the amount of $500.00 due to neglect/lack of supervision resulting in resident #1 injuries.

The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).

A telephonic exit interview was conducted with Jesse Mota and a copy of this report and appeal rights provided via email for signature

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20190327091300

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: 04/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/22/2019 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required......	1 2 3 4 5 6 7	Facility will submit a plan to meet the needs of the residents when they are a Fall Risk to prevent falls. The plan will be submitted by 11/22/19. A training shall be held with the staff on the procedure and protocol of the new plan put in place. A copy will be sent to CCL: Attn: Shawna Day @ 323 980 4912 fax by POC date 11/22/19
	8 9 10 11 12 13 14	This requirement is not met as evidenced by :R#1 had multiple falls in the facility, in which she was injured and the facility did not put a plan in place to prevent R#1 from the falls although the facility identified R#1 as a Fall Risk. This poses an Immediate Health and Safety risk to resident in care.	8 9 10 11 12 13 14
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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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC9099 (FAS) - (06/04)

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