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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 06/09/2021
Date Signed: 06/09/2021 02:27:02 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
06/01/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210601170213
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: 71DATE:
06/09/2021
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Jesse Mota, administratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff did not provide assistance to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA) Vasallo and Margaryan conducted a complaint visit to investigate the allegation listed above. LPA's met with administrator, Jesse Mota and explained the reason for the visit.

The investigation consisted of the following: LPA's interviewed 8 residents and 7 staff during the visit. LPA's also toured the facility. LPA's obtained and resident and staff roster and reviewed residents' files.

The investigation revealed the following: It's alleged a caregiver did not assist Resident #1 (R1) recently with toileting and or bed pan. Staff interviewed denied having any knowledge of the alleged incident and deny that they don't assist with toileting. Residents interviewed did not have any negative statements to make about caregivers. Residents did not corroborate the allegation. There were not witnesses, staff or residents, to the alleged allegation.

Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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 2
Control Number 28-AS-20210601170213
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: 06/09/2021
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held with administrator and a copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2