191290642-4-26-2021-28-AS-MVAO-C5AUCM-20210726152810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 04/26/2021
Date Signed: 04/26/2021 11:24:47 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
01/28/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210128145900

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: 74	DATE:	04/26/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jesse Mota		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility is not heated at a comfortable temperature for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings 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 facility administrator.

During the initial investigation, LPA Spencer conducted telephone interviews with administrator Jesse Moto, residents #1-8 (R1-R8), and staff #1(S1). The LPA took a tour of the facility which included the front entrance, 4 resident rooms, hallways, and all central thermometers. The LPA received and reviewed copies of the Staff Roster (LIC 500), Resident roster and maintenance logs from November 2020- February 2021.

***Narrative continued on LIC9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
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)

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Control Number 28-AS-20210128145900

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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The investigation revealed the following:

During the observation, LPA observed that there were 7 central thermometers that were between 67 and 75 degrees Fahrenheit. The administrator stated that rooms 51-88 have individual heating/air units while the central units control the rest of the resident rooms. The administrator stated that the central units remains on automatically. Air conditioning (A/C) will come on when temperature reaches 78 degrees and heat will come on when temperature reaches 68.

Administrator stated that there have been no recent maintenance requests for broken heaters or AC units except for 2 requests from R5 and R8. He stated that both requests were resolved on the same day, but R5 was given a temporary space heater until the wall unit heater could be replaced. LPA attempted interviews with 8 residents. R8 was unable to complete the interview so 7 resident interviews were conducted. 4 out of 7 residents stated that the temperature of their room is uncomfortable.

A review of the maintenance records from November 2020-February 2021 revealed that there were 14 maintenance requests related to heaters or A/C units not working causing uncomfortable temperatures. LPA observed R5's wall unit not in working order and was unplugged/taped to prevent use. Administrator stated that he is unsure when it will be replaced because the A/C company has been hesitant to come out due to COVID-19 but resident was given temporary space heater. S1 also stated that he has had several residents requesting to fix units due to uncomfortable temperatures.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
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: 2 of 3

Control Number 28-AS-20210128145900

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 04/30/2021 Section Cited CCR 87303(b)	1 2 3 4 5 6 7	87303(b) Maintenance and Operation: A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by...	1 2 3 4 5 6 7	The administrator stated that he will ensure that the facility maintains temperatures between 68-78 degrees F. Additional space heaters or fans will be provided for residents who request it. Administrator will provide CCL with pictures of all central thermometers and a letter stating which residents were provided fans or space heaters by 4/30/21.
	8 9 10 11 12 13 14	Based on observations, interviews, and record reviews, the licensee did not ensure that the temperatures of resident rooms were kept at a comfortable temperature. This poses a potential health risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
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)

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