191290642-10-19-2021-28-AS-LHIS-C85MHJ-20211025093736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:04:53 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
10/11/2021 and conducted by Evaluator Noemi Galarza

COMPLAINT CONTROL NUMBER: 28-AS-20211011090946

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: 69	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Jesse Mota, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff is interfering with resident's personal mail.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with Administrator Jesse Mota.

The investigation consisted of the following: A tour of the interior and exterior of the facility and file review was conducted. Resident mailboxes are located in the lobby area. All mailboxes were observed locked. Staff (S1- S4) and residents (R1 -R8) were interviewed. The following documents were obtained: Resident (R1's) Identification and Emergency Information, Physician Report, Admission Agreement, Assisted Living Waiver Individual Service Plan, AppraisalNeeds and Services Plan, House Rules, resident roster, staff roster, and Medi-Cal eligibility verification.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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-20211011090946

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: 10/19/2021

NARRATIVE

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Allegation: "Facility staff is interfering with resident's personal mail." Based on interviews conducted the findings indicate that staff have not interfered or tampered with none of the resident's mail. Eight (8) out of eight (8) residents interviewed stated they have had no issues with their mail. Resident (R1) stated that at this time there are no issues with mail, but believes the mail should be handled more securely by ensuring that during mail sorting and the phone rings the mailboxes are not left unattended. The locked resident mailboxes are located in the lobby area by the front office reception area. There are two (2) residents in the facility that request staff assistance in opening and reading their mail due to language barriers. One (1) of the resident's stated that staff only open the mail when giving consent.

Administrator stated that mail gets sorted out at the front desk and then gets put into the resident mailboxes only by front office receptionist. All residents have a key to the mailbox. If a resident is bed ridden the mail is taken to the resident's room by the Activity Department staff. Occasionally a couple residents ask for assistance with their mail, and it is opened and read with resident's permission. All four (4) staff interviewed denied interfering or tampering with resident's mail. Per staff interviews, there are a few residents whose family instructs staff to hold their mail. It was also stated that sometimes residents ask for assistance in opening packages that are delivered. Staff stated that resident (R1) has active Medi-Cal benefits; therefore staff have not interfered with Medi-Cal Redetermination mail documents as alleged in this complaint. Staff check Medi-Cal eligibility once a month. A copy of active Medi-Cal eligibility was obtained.

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.

Exit interview was held with Administrator Jesse Mota. A copy of the report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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