191290642-6-3-2021-28-AS-MVAO-C5HTLM-20210802144947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 06/02/2021
Date Signed: 06/03/2021 08:02:11 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
01/04/2021 and conducted by Evaluator Glenn Trueman

COMPLAINT CONTROL NUMBER: 28-AS-20210104143316

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:	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Assistant Administrator Celia Garcia		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident wandering facility knocking on other residents doors

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Office Manager Cynthia Valdez and explained the reason for the visit.
Shortly thereafter Assistant Administrator Celia Garcia arrived and Administrator Jesse Mota arrived.
The purpose of the visit is to conduct a subsequent complaint visit from the original complaint dated 1/4/2021.
At today's visit Resident's # 1-5 were interviewed from 10:00 AM to 10:30 AM.
Staff 1- 4 were interviewed at 9:15 AM. to 10:00 AM.
Staff and Resident Roster was submitted.
In regards to the above allegation Resident wandering facility knocking on other residents doors, based on interviews conducted and information gathered it was revealed that Resident's 1-5 stated that no residents have wandered and knocked on their door.
They stated that staff are professional and take care of all their needs and services and act promptly when they need help. 1 resident interviewed stated that they knew Resident # 6 and she had wandered and knocked on doors rarely, but staff were great and did everything possible to have her under control and under supervision.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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-20210104143316

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: 06/02/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff interviewed stated that resident # 6 wandered a couple of times and said she didn't see well and would reach for different rooms not knowing which was hers.
Stated that there was immediately an in service meeting and staff would redirect Resident # 6, do activities and take walks outside to calm her.
Residents and staff interviewed stated that residents are checked often and staff act professional and promptly taking care of all needs of the residents.

Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2