191290642-3-17-2022-28-AS-LHIS-CCXR53-20220328124225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 03/17/2022
Date Signed: 03/17/2022 04:18:49 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 PM
MET WITH:	Jesse Mota, Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility doors are in disrepair.
Staff do not safeguard the premises for the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Galarza and Baptiste conducted a subsequent complaint visit to deliver findings on the above allegations.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

Unsubstantiated

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: Facility doors are in disrepair. It is alleged that the automatic fire doors are in disrepair, making intermittent buzzing noises, and are being held by rubber stoppers in order to prevent the doors from closing. Based on physical plant observation, LPA observed that all corridor fire doors were operable and not in disrepair. The issue was addressed and fire door doors were repaired on November 29, 2021; technicians installed six (6) magnetic door holders with a safe operation, tri-volt coil and adjustable armature plate for safe and proper function. Staff stated that the corridor fire doors are latching properly now. All residents interviewed stated the fire doors were repaired approximately 4 months ago. Staff and residents have not observed the fire doors to be closed. However, two (2) wooden stoppers were observed in the bottom of both fire doors near room 59. Administrator stated that the stoppers were placed there in order because the call light system was being repaired, and the electricity was turned off during the repairs.

Allegation: "Staff do not safeguard the premises for the residents." Based on observation and interviews conducted the findings indicate that the Mariposa St exit door, located in the west side of the building, which leads to the street sidewalk is always closed. Residents and staff may exit and use that door, but are not able to enter back because it requires a key. Only maintenance and front office staff have a key to that door. It is alleged that night shift staff are use the Mariposa St exit door, and residents do not feel safe. However, seven (7) out of seven (7) residents stated that exit door is always closed, and they feel safe. LPA inspected the door, and confirmed the door is operable and latch closes properly. In addition, the door requires a key from the outside in order to re-enter through that door. Staff conduct rounds during nighttime hours and have not observed any health and safety concerns, or the door to be opened.

Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was held with Administrator Jesse Mota. A copy of the report was provided.

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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