191290642-8-13-2021-28-AS-SCOL-CDDT24-20220411142003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/13/2021
Date Signed: 08/13/2021 01:15:33 PM

Unsubstantiated

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
01/27/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210127094715

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	POLITA BARNES		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 71	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Jesse Loera Mota; Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are poisining resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Cynthia Valdez (Office Manager) and explained the reason for the visit. Administrator Jesse Loera Mota arrived shortly thereafter.

The investigaton revealed the following: during the initial televisit conducted on 02/03/21, LPA interviewed the Administrator and obtained copies of Resident & Staff Rosters. During today's visit, LPA toured the kitchen and interviewed Resident #1 (R1), and Staff #1 - Staff # 5.

The investigation revealed the following: in regards to the allegation "staff are poisining resident in care", it is alleged that the Administrator paid someone to poison the food of R1. Interview conducted with Administrator denied the allegation. During tour of facility kitchen, LPA did not observe any poisons or toxins in proximity to the food preparation. Interviews conducted with staff members all denied the allegation. There were no witnesses, staff or residents to the alleged allegation. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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-20210127094715

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: 08/13/2021

NARRATIVE

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LPA toured R1's bedroom and did not observe any poisons or toxins. R1 indicated during interview that she was unsure if it was staff or "someone from the outside" who had poisoned her food. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 held, and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

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