191290642-8-13-2021-28-AS-MVAO-C75PXX-20210923114304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/13/2021
Date Signed: 08/13/2021 01:13:49 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
12/21/2020 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201221135148

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: 71	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jesse Loera Mota; Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not notice a change in the resident's condition.
Staff did not change resident's diapers.
Staff not responding to resident's alarm.
Staff did not ensure resident was eating.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Cynthia Valdez (Office Manager) and explained the reason for the visit. Administrator Jesse Loera Mota arrived shortly thereafter.

The investigation consisted of the following: during initial televisit conducted on 12/22/20, LPA interviewed the Administrator and obtained copies of resident and staff rosters and documents from Resident #1's File. During today's visit, LPA toured the facility and interviewed Resident #2 - Resident #9 and Staff #1 - Staff #5. LPA was unable to interview R1 as R1 moved out of the facility on 12/13/20.

The investigation revealed the following: in regards to the allegation "staff did not notice a change in the resident's condition" R1 was transported to Glendale Adventist on 12/13/20 due to high fever and refusing to eat. R1 was diagnosed with a UTI.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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-20201221135148

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: 08/13/2021

NARRATIVE

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Interviews conducted with staff members revealed that resident temperatures are monitored and checked at least once a day. Per Administrator, resident families are immediately notified if a change in condition is observed and primary physician is also contacted. If residents need immediate attention, they will be transported to the hospital. Interviews with residents also confirmed this information. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "staff did not change resident's diapers", it is alleged that staff did not assist R1 with diaper changes. Interviews conducted with staff members revealed that residents are monitored and checked on every 2 hours. Staff members assist residents with diaper changes as needed. Interviews conducted with residents revealed that staff members assist them with diaper changes. Residents revealed being happy with staff members. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "staff not responding to resident's alarm", it is alleged that staff do not monitor the call light system. Call light will allegedly be on for hours and no one will respond. During today's visit, LPA toured the facility and pulled the cord in room #45 and observed a caregiver attend to the room in 3 minutes. LPA verified that call light system is currently working. Interviews conducted with staff members revealed that front office will "walkie talkie" or paige them when an emergency cord is pulled and they will respond to that room as soon as possible. Interviews conducted with residents revealed that staff will respond to their room in a timely manner whenever they pull the emergency cord. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "staff did not ensure resident was eating", it is alleged that staff members do not assist residents with eating. Interviews conducted with staff members revealed that staff provide residents assistance as needed. Staff members also revealed that residents are offered 3 meals a day and 2 snacks a day. Interviews conducted with residents revealed that they receive assistance from staff members if they request assistance. Interviews conducted with residents revealed they are provided with 3 meals and 2 snacks. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

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