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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 04/26/2021
Date Signed: 04/27/2021 04:40:59 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
04/19/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210419121641
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:JESSE MOTAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 72DATE:
04/26/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Jesse MotaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff does not treat residents with dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos 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 Administrator Jesse Mota.

During today's investigation, LPA interviewed Staff #1-#5 (S1-S5), residents #1-#8 (R1-R8) and reviewed R1s Facesheet and physicians report. LPA reviewed a written notice given to S1 by S2.

In regards to the allegation "Staff does not treat residents with dignity and respect." it was alleged that S1 had verbally insulted R1 in the facility on 4/17/21. Interviews with (2) of (5) staff interviewed corroborated the allegation and (3) of (5) staff could not. (7) of (8) Residents interviewed could not corroborate the allegation. Interviews with the staff show that while S1 was helping R1 change their soiled linens, both began to argue about the best method in doing so...

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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 5
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
04/19/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210419121641

FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:JESSE MOTAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 72DATE:
04/26/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Jesse MotaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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9
facility staff refused to change resident soiled linens.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos 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 Administrator Jesse Mota.

During today's investigation, LPA interviewed Staff #1-#5 (S1-S5), residents #1-#8 (R1-R8) and reviewed R1s Facesheet and physicians report. LPA reviewed a written notice given to S1 by S2.

In regards to the allegation "facility staff refused to change resident soiled linens." it was alleged that staff#1 refused to change resident #1's soiled linens. (5) of (5) staff interviewed denied the allegation. (7) of (8) residents interviewed could not corroborate the allegation. Review of R'1s file show that R1 requires assistance with toileting and personal hygeine. interviews show that on 4/17/21 as S1 was helping R1 with toileting and personal hygeine, there was a verbal diagreement in the best method to do so.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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 5
Control Number 28-AS-20210419121641
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: 04/26/2021
NARRATIVE
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This caused an argument where S1 left R1's room to get assistance from S3. S3 spoke with R1 and was able to get S1 back into the room to continue helping R1. LPA was unable to gather information that showed facility refusing to change R1's soiled linens. Based on statements and interviews conducted with clients and staff as well as LPAs file reviews, there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all the allegations are UNSUBSTANTIATED.

A telephonic exit interview was conducted with administrator Jesse Mota and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210419121641
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: 04/26/2021
NARRATIVE
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According to the interviews with (2) of (5) staff, R1 verbally insulted S1 and in retaliation, S1 insulted R1 before walking out of the room. Documents collected and reviewed show that S1 received a written notice due to the incident. The notice is dated 4/17/21 and has a written statement from S1 admitting the allegation occurred. This showed that the staff failed to treat the resident with dignity and respect. Based on LPA's interviews and file review conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit Interview was conducted via telephone with the administrator and a hardcopy was provided via email to Administrator Jesse Mota for signature. Appeal Rights given and discussed.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210419121641
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: 04/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2021
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Adminstrator agreed to conducted in service training on resident personal rights and submit proof with staff signatures by POC due date.
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Based on interviews, and record reviewed, the Staff#1 did verbally insult resident #1 in the facility. This poses a potential health risk to persons in care.
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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 FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5