191290642-8-20-2021-28-AS-MVAO-CALUM8-20220112144154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:36:07 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
03/04/2021 and conducted by Evaluator Nina Galarza

COMPLAINT CONTROL NUMBER: 28-AS-20210304094320

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:	08/20/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jesse Mota		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff made inappropriate comments towards resident

INVESTIGATION FINDINGS:

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On 8/20/2021 Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan conducted an unannounced subsequent visit regarding the allegation listed above, intially reported 3/4/2021. LPAs met with Administrator Jesse Mota and stated the purpose of the visit.
The investigation consisted of interviews with Staff 1, (S1), Staff 2 (S2), Staff 3 (S3) Staff 4 (S4), Residents 1-7 (R1-7).
On 3/10/2021 LPA Katrdzhyan interviewed S1 and S2. S1 and S2 denied the allegation.On 8/20/2021 LPAs Nina Galarza and Nune Margaryan interviewed S3 and S4. S3 and S4 denied the allegation.
On 8/20/2021 (6) out of (7) residents denied staff making innappropriate comments towards them. (7) out of (7) residents stated the staff treat them well and assist them with all their needs. (6) out of (7) residents stated they have not heard of other residents complaining about staff making inapppropriate comments towards them.
CONTINUED 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

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-20210304094320

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: 08/20/2021

NARRATIVE

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The following documents were provided to LPA Katrdzhyan on 3/10/2021; • Functional Capability Assessment • Appraisal/Needs and Services Plan • Physician’s Report • Resident Roster.

The following documents were provided to LPAs Nina Galarza and Nune Margaryan on 8/20/2021; staff and resident roster.

The investigation revealed of the following: "Staff made inappropriate comments towards resident." On 8/20/2021 LPAs Nina Galarza and Nune Margaryan interviewed residents and (6) out of (7) residents denied staff making inappropriate comments towards them. (7) out of (7) residents stated the staff treat them well and assist them with all their needs. All staff have denied allegation.

Although the allegation may have happened or are 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 conducted, a copy of this report and Appeal Rights were provided to Celia Garcia.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

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