191290642-6-3-2021-31-AS-MVAO-C4WUNN-20210714154413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 06/03/2021
Date Signed: 06/03/2021 04:58:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2020 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20200519091405

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:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jesse Mota		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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8
9

Facility did not provide a copy of resident's records to the resident's authorized representative

INVESTIGATION FINDINGS:

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5
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9
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Licensing Prorgram Analyst (LPA) Pitz conducted an unannounced visit on this day in order to deliver investigation findings into the above allegation.
As part of this investigation, LPA interviewed the complainant and facility staff #1 (S1).

Allegation #1, that "Facility did not provide a copy of resident's records to the resident's authorized representative," has been substantiated based on the interviews conducted.

LPA was able to confirm that Resident #1's (R1's) records were requested by their authorized representative on 5/17/20 but not furnished by the facility until 6/8/20. Facility staff stated that they store former resident records in an offsite location which caused the delay.

Report reviewed, exit interview conducted, and a hard copy was provided via email for signature.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 5964342
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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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