191290642-6-23-2021-28-AS-LHIS-C76UBA-20210924152601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 06/23/2021
Date Signed: 06/23/2021 01:42:47 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
06/16/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210616125133

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	JESSE MOTA		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 72	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jesse Loera Mota, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility did not fix the phone jack in resident's room in a timely manner.
Facility did not provide resident internet access resulting in extra charges.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA met with Jesse Loera Mota, the Administrator and explained the purpose of the visit.

During today’s visit, LPA Chan interviewed the Administrator, 4 Staff, and 7 Residents. LPA obtained a copy of the staff roster, resident roster, AT&T service bill, and the Admission Agreement for Resident #1. LPA Chan interviewed Residents #1 - #7.

The investigation revealed the following:
Allegation #1 - Facility did not fix the phone jack in resident's room in a timely manner. It is alleged that it took more than 5 months to service the phone jack in room #62. Per Administrator Loera Mota and Staff interviewed, they stated that they are unable to test the phone jack to ensure that it works until residents request to install a phone or internet service. Administrator stated that it was brought to his attention sometime in April 2021 when Resident #1 (R1) tried to obtain internet services from AT&T.
(Continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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-20210616125133

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: 06/23/2021

NARRATIVE

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When the technician came out, it was determined that the signal to receive internet services was weak in room #62 and not that the phone jack was non-operational. Per Administrator, the technician said that they can install a phone line in the room so it was not in disrepair. After he was informed that the signal for internet was weak in room #62, he offered to move Resident #1 to another room with better signal. R1 agreed and moved to the other room on 4/30/21. LPA received a copy of the AT&T billing invoice for 4/10/21 that the tech support service was requested between 3/16/21 - 4/24/21. LPA interviewed the maintenance staff who stated that room #62 was checked for any wiring issues once it was reported that the phone jack was not working in April 2021. Other staff interviewed did not hear any residents complained that their phone jack was working in the past. There was not sufficient evidence to support this allegation.

Allegation #2 - Facility did not provide resident internet access resulting in extra charges. LPA interviewed the Administrator and 4 Staff who indicated that the residents’ rooms are equipped with a phone jack. They stated residents are aware any extra items such as a phone line, cable, and internet services are not part of a resident’s monthly rate. The residents are responsible for installing and paying for extra services. LPA interviewed 7 Residents and all but one stated that they are aware the facility does not provide internet and they pay for that service themselves. LPA reviewed the Admission Agreement for R1 and it does not state internet access is included in the basic monthly rate.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Celia Garcia. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC9099 (FAS) - (06/04)

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