191290642-5-4-2021-28-AS-MVAO-C5AUNR-20210726154422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 05/04/2021
Date Signed: 05/04/2021 03:37:56 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
01/07/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210107102753

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:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Jesse Mota		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff interfered with resident's ability to obtain medical treatment

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 course of the investigation, LPA Spencer conducted telephone interviews with the administrator, assistant administrator, staff #1 (S1), and residents #1-7 (R1-R7). R4 and R5 could not complete interviews due to being non-verbal, so 5 resident interviews were completed. The LPA reviewed copies of the Staff Roster, Resident roster and for R1: face sheet, Needs and Services plan, Medi-Cal eligibility report, admissions agreement, and related letters/emails written by R1.

***See LIC9099C for continuation of this narrative.

Unsubstantiated

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: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

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-20210107102753

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: 05/04/2021

NARRATIVE

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The investigation revealed the following:

It was alleged that a staff member tipped off the Department of Social Services regarding R1's alleged assets, causing them to send a re-determination letter for Medi-Cal eligibility. All staff interviewed denied contacting anyone regarding R1's alleged assets. S1 stated that she oversees Medi-Cal eligibility for residents and that almost all residents are eligible for Medi-Cal. S1 stated that residents must report their own assets unless the facility is listed as a payee. S1 said that R1 has made claims that she has assets but she still shows as eligible for Medi-Cal.

The administrator stated that R1 has hallucinations about being rich but he has not contacted anyone regarding these claims. LPA Spencer reviewed R1's Needs and Services Plan which states that the resident has delusional disorder and schizoaffective disorder. In letters written by the resident, she alleges that she has inherited assets through her blood line and that family members are trying to take control of the assets.

In an interview, R1 stated that she was able to get the matter resolved when talking to her case worker who said that she does not need to fill out the re-determination form because it does not apply to her. She also stated that she did not lose Medi-Cal coverage. Upon review of the records, the Medi-Cal eligibility report shows that R1 is still eligible for Medi-Cal. All other residents interviewed stated that that the facility has not interfered with their ability to obtain medical treatment or coverage and have not heard of other residents making this claim.

Based upon interviews and records reviewed, the findings indicate that although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

A telephonic exit interview was conducted, a copy of the report was emailed, and staff was instructed to sign and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

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