191290642-4-1-2022-28-AS-NMAN-CD3TBS-20220401143536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 04/01/2022
Date Signed: 04/01/2022 02:35:44 PM

Document Has Been Signed on 04/01/2022 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	JESSE MOTA		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 68	DATE:	04/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Office Manager Cynthia Valdez and Administrator Jesse Mota		TIME COMPLETED:	02:30 PM

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	Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Cynthia Valdez, Office Manager and explained the reason for the visit. Shortly after Administrator Jesse Mota arrived. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 4 hospice residents. There are currently 3 residents on hospice. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit. Resident bedrooms were randomly chosen for review. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was between 110.5 - 113.7 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. LPA observed sufficient seven day non-perishable and two day perishable food supplies. All the appliances are clean and operating properly. Common areas were observed clean and properly furnished. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Continue LIC 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/01/2022

NARRATIVE

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The facility has a sprinkler system with wired alarm. Fire extinguishers are present through the facility and are fully charged. LPA observed the facility had the required carbon monoxide detectors in each of the resident's apartments.
LPA reviewed 6 resident files to confirm emergency contact is updated and residents have health screenings on file. 4 staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 6 residents' medications.
LPA observed that on Medication Administration Record (MAR) for Resident #1 (R1) medications were not administrated as prescribed by physician. R1's MAR log was missing signatures for February and March although the medications were administered.

Per California Code of Regulations, Title 22, the deficiency observed is documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/01/2022 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above. LPA observed that on Medication administration record (MAR) for Resident #1 (R1) medication was not administrated as prescribed by physician. R1's MAR log was missing signatures for February and March although the medication was administered. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2022
	Plan of Correction
1 2 3 4	Administrator shall conduct medication administration training for all staff who administer medication. Administrator will send LPA proof of material covered and in-service sign in sheet by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC809 (FAS) - (06/04)

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