191290642-12-20-2021-28-AS-MVAO-CC5UPP-20220302144553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/20/2021
Date Signed: 12/20/2021 02:57:23 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
07/09/2020 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200709115233

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:	12/20/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Celia Garcia (Assistant Administrator)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident given medications that were not prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Celia Garcia (Assistant Administrator) and explained the purpose of the visit.

During the initial complaint investigation on 07/17/20 which was conducted telephonically, LPA Juan Miramontes emailed Assistant Administrator requesting the following documents to be emailed or faxed to LPA's attention: Personnel Report (LIC500), with contact phone numbers; Register of Facility Residents (LIC9020) [or equivalent], Policy and Procedures on Medication Administration, including staff training; and from Resident's #1 (R1) facility record file: Physician's Report (LIC602A) and list of prescribed medications, including written orders from physicians.

Continue to LIC9099C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

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-20200709115233

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: 12/20/2021

NARRATIVE

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During today's visit, LPA Kruz Long obtained a copy of the Staff Roster, Resident Roster and Medication log for Resident #1. LPA interviewed Staff #1 through #9 in the conference room between 10:09 am to 11:48 am, toured various resident rooms with Staff #10 at 12:05 pm, interviewed Resident #1 in the bedroom at 12:28 pm and interviewed Resident #2 through #8 in the conference room between 1:15 pm to 2:10 pm.

In regards to the allegation: Resident given medications that were not prescribed. A review of Resident #1's medication log indicated that Staff did not give Residents medication that were not prescribed. Interview with Resident #1 indicated that it wasn't not witnessed whether Staff gave Resident medications that were not prescribed but merely a speculation. Interviews with Resident #2 through #8 indicate that medications that were not prescribed to them were never given to them and interviews with Staff indicate that staff not designated with medication assistance have no access to resident medications. Staff designated to assist Residents with medications does so based on doctor's order.

Based on LPA's record review and interviews, investigation revealed, 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 conducted with Jesse Mota (Administrator) and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC9099 (FAS) - (06/04)

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