191290642-2-18-2022-28-AS-LHIS-CD6HVS-20220404063225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 02/18/2022
Date Signed: 02/18/2022 04:31:45 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
02/14/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220214110935

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:	02/18/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Simonette Alanes, Activity Director		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff is not providing adequate supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted the complaint investigation for allegation – Staff is not providing adequate supervision. LPA arrived unannounced and met with the Activity Director, Simonette Alanes, who assisted with the visit. The purpose of the visit was explained.

The investigation consisted of the following:
LPA toured the facility with the Activity Director. LPA obtained copies of the Staff roster, Resident roster, and conducted interviews with the Administrator, 6 Staff, and 7 Residents.

The investigation revealed the following:
In regards to the allegation, Staff is not providing adequate supervision, LPA did not find any evidence to support this allegation. Per the Administrator, staff are providing adequate supervision. Staff providing supervision are the Administrator, Assistant Administrators, caregivers, Med Techs, and housekeepers.
(Continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

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-20220214110935

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: 02/18/2022

NARRATIVE

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There are approximately 9 staff the morning shift, 6 in the evening shift, and 2 in the NOC shift who provide care and supervision to the residents. Staff interviewed stated they work as a team and will check on residents about every 2 to 3 hours, including the evening and overnight shifts. Staff stated that residents usually go to their rooms after dinner and do not hang out in the hallways. If anyone is seen in the living room or out of their rooms, they will check on them to ensure they do not need any assistance. LPA interviewed 7 residents and 6 out of 7 indicated that there is adequate supervision at the facility. Staff tend to them quickly and check on them.

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.

An exit interview was conducted with the Assistant Administrator. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

LIC9099 (FAS) - (06/04)

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