191290642-12-24-2021-28-AS-MVAO-CCEP9S-20220311100736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/24/2021
Date Signed: 12/24/2021 06:29:42 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
12/20/2021 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20211220143434

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	JESSE MOTA		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 71	DATE:	12/24/2021
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Jesse Mota, Administrator		TIME COMPLETED:	01:28 PM

ALLEGATION(S):

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Alarmed doors prevent resident leaving their hall.

Resident's call light is not functioning properly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Celia Garcia (Assistant Administrator) and explained the purpose of the visit. Administrator Jesse Mota met LPA a few minutes later at 9:33 am and LPA discussed the purpose of the visit. LPA toured various resident rooms with Administrator

LPA interviewed Administrator and requested a copy of the Staff/Resident roster and repair log.

During today's visit, LPA Lopez obtained a copy of the Staff Roster, Resident Roster and Repair log. AT 9:48 am LPA interviewed Resident #1 in the bedroom and at 9:56 am interviewed Resident #2 in bedroom. LPA interviewed R#3 -R#7 in conference room. LPA interviewed Staff #1 through #7 in the conference room.

Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2021

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-20211220143434

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: 12/24/2021

NARRATIVE

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In regard to the allegation: Resident's call light is broken. LPA toured various resident bedrooms in the facility and observed that call lights were 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, or fire doors malfunction they are repaired in a timely manner. LPA tested the call light in several rooms and was operational and staff responded in 7 minutes or less.

In regard to allegation: Alarmed doors prevent resident leaving their hall. LPA toured the facility with administrator and did not observed any of the fire doors closed. 7/7 staff stated they have not observed alarm doors closed. S#2 stated that the alarm/fire doors are only closed during power outage or fire drill and never at any other time. 5 of 7 residents interviewed stated that they have not seen the fire doors closed recently. 2 of 7 residents stated that one door was recently closed due to repairs and it was only for few hours and did not impede passage.

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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2021

LIC9099 (FAS) - (06/04)

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