191290642-5-11-2024-31-AS-NMAN-D5HT2G-20240522142044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 05/11/2024
Date Signed: 05/11/2024 02:44:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/31/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230531115401

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	CELIA GARCIA		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(323) 697-2248
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	0	CENSUS: 144	DATE:	05/11/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Rosie Carrillo		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff do not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced subsequent complaint visit to the facility on 05/11/2024. LPA met with facility staff and disclosed the purpose of the visit. The Assistant administrator Brandy Rangel was not present at the facility. The administrator was contacted and authorized staff to sign.

Staff do not safeguard resident's personal belongings

It was alleged that Staff are not safeguarding Resident #1 (R1) incontinent supplies, toothpaste and coin money. A 24-hour visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/01/2023, at which time LPA Smith observed facility hall storage and interviewed staff. LPA was unable to interview Resident #1 (R1) as R1 was not present at the facility during visits and the reporting party was not reachable for interview via contact information provided.

(Cont. to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024

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 31-AS-20230531115401

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 05/11/2024

NARRATIVE

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(Cont. from 9099)

Interview with the administrator on 06/01/2023, revealed that residents keep their own hygiene supplies in their individual room. Two (2) of two (2) staff reveal residents have a room key and are responsible for locking their own door when leaving their room and residents also have the option of keeping pilferable hygiene products in facility storage. Administrator revealed that R1 requested to have incontinent items stored in facility hall closet but does not recall when but believes it has been for over several months now. LPA Smith observed R1s incontinent supplies in the facility hall closet on 06/01/2023 with name on item. Interview with seven (7) of seven (7) residents reveal have a room key they are responsible for, and none of their personal belongings taken from their room.

Based on LPA observation and interviews although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024

LIC9099 (FAS) - (06/04)

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