191290642-8-17-2020-28-AS-MVAO-BTPMYV-20200922100211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/17/2020
Date Signed: 08/17/2020 06:13:42 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
08/12/2020 and conducted by Evaluator Renee Arterberry

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200812112600

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: 88	DATE:	08/17/2020
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Jesse Mota, assistant administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff mishandled resident's funds

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ren’ee Arterberry initiated a 10- Day Complaint Visit to investigate the allegation noted above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures today's complaint investigation was conducted telephonically with Jesse Mota the facility assistant administrator of Leisure Vale Retirement Hotel. The investigation consisted of the following: at 3:37 PM the LPA interviewed the assistant administrator and he shall be referred to as, S1. At 3:50 PM the LPA also interviewed a resident who shall be referred to as R1. At 4:00 PM the LPA interviewed
another staff and she shall be referred to as, S2. The LPA requested and S1 provided a copy of the check written to the facility for the basic services/rent for the month of August 2020 (Check #1612). It is alleged that on August 5, 2020 R1 wrote a check in the amount of $1089.37 to the facility for monthly basic services/rent for the month of August 2020. S2 claimed to have deposited the check on August 6, 2020. As of August 11, 2020, the check balance was not withdrawn from R1's bank account. It is suspect that S1 was attempting to make a debit purchase or withdrawal from R1's bank account in order to bounce the Leisure Vale rent check. The investigation reveal the following: S1 acknowledge that Check #1612 was given to S2 as rent payment for

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee Arterberry	TELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

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-20200812112600

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: 08/17/2020

NARRATIVE

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The month of August. Due to a deposit delay the check was not deposited until August 10th. Therefore, the check for basic services/rent for the month of August was not withdrawn from R1's bank account until August 11th. The LPA requested that R1 check her bank account (online) while the LPA was on the phone. R1 acknowledge that the amount of $1089.37 was withdrawn from her bank account on August 11th. The LPA also requested proof that S1 was attempting to make a debit purchase or withdrawal from R1's bank account. The LPA asked R1 if there are withdrawals from her bank account that S1 made and she states, " no I have no proof that S1 made withdraws from my account". S1 state that the only withdraw he made was the one of August 11th for the basic services rate/rent. S1 deny that he made withdraws or was attempting to make withdraws from S1 bank account. S1 also deny that he is attempting to legally or illegally evict R1. S2 state that there was a delay in the deposit and therefore, the withdraw was not made until August 11th.

A review of Check #1612 in the amount of $1089.37 dated August 5, 2020 is proof that R1 paid the rent in the month of August.

The complainant and two staff members/associate administrators were interviewed.
A copy of check number #1612 was provided and reviewed. The state of California, Department of Social Services Community Care Licensing investigated the allegation of, facility staff mishandled resident's funds an the finding is unsubstantiated. Although the withdraw of the basic services rate/rent for the month of August was delayed there is no evidence to support that S1 attempted to withdraw or made unauthorized withdraws from R1's bank account. 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 complaint investigation of the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted via telephone with the administrator and a hardcopy was provided via email for signature. Signatures on hardcopies.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee Arterberry	TELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

LIC9099 (FAS) - (06/04)

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