191290642-12-8-2021-28-AS-MVAO-CC5QUK-20220302112853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:54:59 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
12/18/2020 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20201218101844

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: 69	DATE:	12/08/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator Jesse Mota and Assistant Administrator Celia Garcia		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not safeguarding residents personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent complaint visit to complete the investigation and deliver finding for the allegation listed above. LPA met with Administrator Jesse Mota and explain the purpose for today’s visit.

It was alleged that facility staff used Resident #1’s (R1’s) diapers for other residents resulting in R1 not having a sufficient supply for personal use.
The investigation was initiated by the LPA Joe Katrdzhyan and continued by the LPA Nune Margaryan.
During investigation, on 12/23/20 LPA Katrdzhyan interviewed the Assistant Administrator and requested copies of relevant documents.
On 11/10/2021 from approximately 9:50 am to 1:30 pm LPA Margaryan conducted interviews with 7 (seven) residents and 6 (six) staff. Also was provided copies of documents related to the allegation.

Continued 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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-20201218101844

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: 12/08/2021

NARRATIVE

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Administrator indicated that residents’ incontinent supply/diapers are not listed on the Residents Personal Property and Valuable form as they are consumable. Staff denied using R1’s incontinent supply for other residents. Furthermore, they indicated that facility has a sufficient amount of incontinent supply including diapers to use for the residents requiring incontinent care.

Residents interviewed during investigation addressed no concerns regarding their personal belongings and/or incontinent supply. During today’s visit at 2:00 pm LPA Nune Margaryan inspected the facility and observed sufficient amount of diapers in the storage room at the facility. Residents roster and Staff roster were provided.

Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation deemed UNSUBSTANTIATED at this time.

An exit interview was conducted with Assistant Administrator Celia Garcia and a hard copy was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC9099 (FAS) - (06/04)

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