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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 11/10/2021
Date Signed: 11/10/2021 02:03:58 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
01/25/2021 and conducted by Evaluator Nune Margaryan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210125120138
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:POLITA BARNESFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 69DATE:
11/10/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Celia Garcia: Assistant Administrator/
Jesse Mota: Administrator 		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff are threatening to harm resident
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Nune Margaryan. Upon arrival LPA met with Assistant Administrator Celia Garcia. Shortly thereafter Administrator Jesse Mota arrived at the facility. The purpose of today's visit was explained.

Regarding the allegation of: Facility staff are threatening to harm resident.

An initial 10-day telephonic complaint visit was conducted on 02/01/2021 by LPA Joe Katrdzhyan at which time an interview was conducted with the administrator.

During this visit from approximately 9:50 am to 1:30 pm LPA conducted interviews with 7 (seven) residents including the resident named in the complaint and 6 (six) staff. When interviewed none of the residents reported administrator and/or staff threatening to harm them. In addition, interviewed staff denied threatening to harm any resident or being aware of other staff doing so.

. Continued 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20210125120138
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: 11/10/2021
NARRATIVE
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Based on the information obtained from the interviews conducted the department did not obtain sufficient information to determine that “Facility Staff are threatening to harm resident” therefore the allegation is Unsubstantiated at this time.

Exit interview conducted and a copy of report issued.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2