191290642-3-17-2022-28-AS-LHIS-CCXR52-20220328124225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 03/17/2022
Date Signed: 03/17/2022 04:15:28 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
03/09/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220309110454

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:	03/17/2022
		UNANNOUNCED	TIME BEGAN:	02:45 AM
MET WITH:	Jesse Mota, Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Resident's call lights are in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Galarza and Baptiste conducted a subsequent complaint visit to deliver findings on the above allegation.The purpose of the visit was discussed with Administrator Jesse Mota.

The investigation consisted of: On 3/16/22, a physical plant inspection of the interior and exterior was completed. The call light system, fire doors, resident rooms, and facility exits were inspected. A total of 12 rooms call light system was tested [54,55 (bulb out), 57 (bulb out), 59, 61, 62, 63, 64, 65, 75, 76, 82]. Staff (S1-S4) and residents (R1- R7) were interviewed. LPA obtained the following documents: Call light system service invoice [3/16/22], fire door repair invoice [11/29/21], LIC 500 Personnel Report, and resident roster were obtained.

See report continuation on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

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-20220309110454

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: 03/17/2022

NARRATIVE

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Allegation: "Resident's call lights are in disrepair." It is alleged that the call light system in the west end of the building was intermittently working, but without sound. Rooms 51-88 have been affected for approximately 4 weeks. On March 11, 2022 technicians evaluated the call light system, and determined the transformer was not working, and the call lights are damaged due to a faulty relay. Several room call light bulbs need replacement. The relay was ordered on March 11, 2022 and is supposed to arrive on March 22, 2022. The chime sound will be fixed once the relay part is installed. All staff interviews confirmed the call light system has not been fully operable in rooms 51-88. Administrator implemented 1-hour checks 24 hours a day to mitigate the call light issue. Five (5) out of seven (7) residents confirmed their room call lights have not been working. During the physical inspection LPA tested the call light system in rooms [54,55 (bulb out), 57 (bulb out), 59, 61, 62, 63, 64, 65, 75, 76, 82], and confirmed the call light system is in need of repair. Chime sounds were not heard. Call light system repairs have been initiated. A service invoice for call light system repairs was obtained. None of the communal restrooms have an alert system.

Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated according to California Code of Regulations, Title 22. See LIC 9099D for citation issued.

Exit interview was conducted with Administrator Jesse Mota. A copy of the report and appeal rights was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220309110454

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/14/2022 Section Cited CCR 87303(i)(1)(B)	1 2 3 4 5 6 7	Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.	1 2 3 4 5 6 7	Administrator shall submit proof that the call light system issues have been repaired.
	8 9 10 11 12 13 14	Based on observation on 3/16/2022, the call light system panel is not working properly, affecting rooms 51-88. The signal system's sound does not work. In addition, some room's light does not work in the panel board; which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

LIC9099 (FAS) - (06/04)

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