191290642-12-20-2021-28-AS-MVAO-CC5US2-20220302144938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/20/2021
Date Signed: 12/20/2021 02:58:09 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
01/26/2021 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210126091918

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):

1
2
3
4
5
6
7
8
9

Facility is in disrepair / resident's call light is broken.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 02/04/21 which was conducted telephonically, LPA interviewed Staff #1 and requested a copy of the Staff/Resident roster and repair log.

During today's visit, LPA Kruz Long obtained a copy of the Staff Roster, Resident Roster and Repair log. 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.

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)

Page: 1 of 2

Control Number 28-AS-20210126091918

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

In regards to the allegation: Facility is in disrepair / resident's call light is broken. LPA toured various resident bedrooms in the facility and observed that call lights and ac/heating unit area operational. Interviews with maintenance and office staff indicate that repairs are immediately completed once staff is notified and broken items are documented in a repair log. LPA reviewed and verified that repair logs are documented. Interviews with 7 of 7 residents indicate that if any items such as call lights, air conditioning/heating units are broken in their bedrooms are repaired in a timely manner.

Based on LPA's record review, observations 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)

Page: 2 of 2