191290642-5-26-2021-28-AS-CYEE-C7ASNS-20210928140200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 05/26/2021
Date Signed: 05/26/2021 02:17:08 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
05/20/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210520122747

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: 70	DATE:	05/26/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jesse Mota (Facility Administrator)		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility advertising services that are not being provided to residents.

INVESTIGATION FINDINGS:

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Licensing Program Licensing (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegation. LPA met with Jesse Mota (Facility Administrator) and discussed the purpose of today's visit.

At approximately 11:30 A.M., LPA interviewed Jesse Mota (Facility Administrator), Cynthia Valdez (Front Office Manager) and Jesus Sanchez (Maintenance). LPA also interviewed Resident #1 through Resident #6 (R-1 through R-6).

LPA collected a copy of the Resident Roster, Staff Roster, Facility Admission Agreement and Facility Brochure.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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-20210520122747

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: 05/26/2021

NARRATIVE

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Allegation: Facility advertising services that are not being provided to residents. During this investigation, LPA interviewed Jesse Mota (Facility Administrator), Cynthia Valdez (Front Office Manager) and Jesus Sanchez (Maintenance). LPA also interviewed Resident #1 through Resident # 6 (R-1 through R-6). Staff interviews revealed Residents’ rooms are equipped with a phone jack for Residents’ use. Staff interviews revealed that phone line services and internet services are not offered as part of the Basic Service. Per staff interviews, Residents are responsible for privately setting up and paying for phone line and/or internet services. Staff indicated they have not received any complaints from Residents and/or Authorized Representatives in regards to this facility not offering private phone lines and/or internet. (5) out of (6) interviewed Residents indicated that this facility does not provide in room phone line and/or internet services. (5) out of (6) interviewed Residents indicated that Residents are responsible for setting up phone line and/or internet services in addition to funding for these services. (5) out of (6) interviewed Residents are aware that phone lines and/or internet services are not part of the Basic Services that are offered. Staff and Resident interviews do not corroborate this allegation.

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 conducted. A copy of this report and Appeal Rights were provided to Mr. Mota.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

LIC9099 (FAS) - (06/04)

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