191290642-3-3-2021-28-AS-ARAZ-C2KNFZ-20210430102620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 03/03/2021
Date Signed: 03/03/2021 04:11:25 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
02/24/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210224131221

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: 73	DATE:	03/03/2021
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Jesse Mota, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide adequate supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza initiated a complaint investigation 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 explained telephonically to receptionist Cynthia Valdez. Administrator Jesse Mota was available later.

The investigation consisted of the following: At 1:55 pm a tele-inspection of the facility lobby, common areas, dining room, and resident (R1's) room was conducted via Microsoft Teams. Resident (R1's) room was observed to be clean and in order. Staff (S1-S9) and residents (R1- R8) were interviewed. The following items were obtained: Resident (R1's) Identification and Emergency Information/Face Sheet, Physician Report, Resident Appraisal, LIC 500 Personnel Report, resident roster, housekeeping room list, and General Program Description policy and procedures.

*** See LIC 9099C for continuation of report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

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-20210224131221

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: 03/03/2021

NARRATIVE

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Allegation: "Staff did not provide adequate supervision." Based on interviews conducted and document review the findings indicate the facility has adequate staffing personnel that provides supervision to residents in care. Nine (9) out of 9 staff interviewed stated residents have adequate staff supervision. None of the staff interviewed had knowledge of any issues with persons entering resident's room without permission, and/or damaging or contaminating resident's belongings. The person that allegedly entered resident (R1's) room does not live or work at the facility. Due to the COVID-19 pandemic, visitors are not allowed inside the building at this time. All person's entering the building are required to sign-in, get screened, and are supervised while in the facility.

Resident (R1) reported that someone grabbed the room door that was slightly opened and pushed it opened. Resident would like additional staffing in the facility, especially during night time hours in order to feel safer. All residents interviewed stated they feel safe at the facility. Resident (R1) suspects "somebody" put poison on the mattress bed sheets. Seven (7) out of eight (8) residents interviewed stated no one has entered their room without permission, and reported no issues with contaminated bed sheets. Bed linens are washed once per week, and/or as needed to address incontinence issues.

According to Administrator all staff are instructed to knock and state their name before entering resident's rooms. There are a total of 37 staff employed, five (5) caregivers, eight (8) caregivers, and three (3) night shift staff. Per, plan of operation "staff is available 24 hours a day to assist with resident needs". Daily housekeeping and ongoing resident observation is performed by staff.

Based upon document review and interviews conducted the findings indicate that, 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.

A telephonic exit interview was conducted with Administrator Jesse Mota. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

LIC9099 (FAS) - (06/04)

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