191290642-5-11-2021-28-AS-MVAO-C2XVFH-20210512162358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 05/07/2021
Date Signed: 05/11/2021 09:46:16 AM

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
12/03/2019 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191203154759

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: 70	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator / Jesse Mota		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff spoke inappropriately to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan 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 conducted telephonically with Jesse Mota, the Administrator.
During the course of this investigation, LPA Katrdzhyan conducted interviews with the Administrator, Assistant Administrator / Nilda Mercado, Staff members 1 and 2 (S1 and S2) and Residents 1 through 6 (R1 - R6). Also, copies of the following documents were obtained and reviewed in reference to R1 and S1;

• Unusual Incident/Injury Reports dated: 11/26/19 and 12/4/19 • Timeline/Notes regarding alleged incident involving R1 and S1 • Identification and Emergency Information for R1 • Letter of Conservatorship for R1 • Physician's Report for R1 • Application for Employment for S1 • Verbal Coaching Notices for S1
• Written Counseling Notice for S1.
(Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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-20191203154759

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: 05/07/2021

NARRATIVE

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The investigation revealed the following;

Allegation: Facility staff spoke inappropriately to resident. The details of this allegation stated that on 11/26/2019, S1 sexually harassed R1 by making inappropriate comments and hand gestures.

After reviewing the facility file of S1, LPA did not observe prior disciplinary actions or write ups regarding personal rights violations involving S1 towards residents. According to the Unusual Incident/Injury Report dated: 11/26/2019, R1 called the Ombudsman and reported an alleged inappropriate proposition from S1. The Ombudsman reported the incident to Administrator / Jesse Mota and upon Mr. Mota's knowledge of the incident, S1 was suspended from work indefinitely pending an investigation. The facility concluded the investigation on 12/4/2019, and the findings were unsubstantiated based on insufficient evidence. According to R1, this was an isolated incident and there were no witnesses to the alleged incident. During an interview with S1, S1 denied making inappropriate comments and hand gestures to R1. From the interviews conducted, majority of the statements obtained described S1 as a good employee. Based on the interviews conducted and record reviews, there is insufficient evidence to support the allegation of "Facility staff spoke inappropriately to resident".

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 Jesse Mota, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

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