191290642-3-29-2022-28-AS-SCOL-CDQLSV-20220422090121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:17:42 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
03/24/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220324113625

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: 69	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Jesse Mota - Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not order incontinence supplies for resident.
Facility did not ensure resident's medications were refilled in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Jesse Mota Administrator and explained the reason for the visit.

The visit consisted of the following: LPA Flores requested a copy of resident roster and staff. LPA Flores conducted interview with administrator, conducted interviews with residents #1,#2,#3,#4,#5,#6,#7, and staff #2 ,#3,#4,#5,#6. Reviewed files for the 7 residents interview, folder with delivery orders for medication, requested copies fo rphysician's report, needs and care plan, admission agreeement for the 7 residents, health care supplier communications and incontinence log for resident #3.

The investigation revealed the following: Regarding allegation: Facility did not order incontinence supplies for resident. It is alleged resident's supply of diapers, liners, and cream has not been ordered for two months. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20220324113625

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: 03/29/2022

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
26
27
28
29
30
31
32

During interviews with residents it was revealed 3 out of 7 residents interviewed stated to have sufficient supplies for incontinence care and to have never run out of supplies, 1 out of the 3 stated facility has provided supplies when her personal order has run low. 3 out of 7 residents stated they did not need supplies for incontinence care. 1 out of 7 residents stated to have received supplies from facility that have been donated. Interviews with staff revealed 3 out of 6 staff interviewed stated residents have sufficient incontinence supplies and when an order is place the order deliver is sufficient for 2 months, facility orders for some residents that need assistance and some residents supplies are provided by resident's representative. 2 out of 6 staff were not familiar with supplies order procedures. 1 out of 6 staff stated the facility has incontinence supplies from donations and provide the supplies to the residents when necessary. Documents reviewed revealed 5 out of 7 residents do not have incontinence concerns and 2 out of 7 residents have incontinence concerns. Appraisal Needs and Care plan reviewed do not note residents require assistance for incontinence care. An incontinence care log was observed for resident #3 for the month of February and March and initialed every two hours.

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

Regarding allegation: Facility did not ensure resident's medications were refilled in a timely manner. It is alleged facility has to order the ibuprofen refill in time to avoid a gap due to change in physician. During interviews it was revealed 7 out of 7 residents stated to have been provided their medication timely and to have never missed a dose. 1 out of the 7 stated that there was a medication that was not provide but that it was the pharmacy who withhold the medication as they needed physician's dosage review. Interviews with staff revealed 4 out of 6 staff interviewed stated resident's medication is in a cycle order and is always replenish for the residents. 1 out of 6 staff interviewed stated to not know about medication orders, but that the med-tech always provides the medication for the residents. 1 out of 6 staff stated to not know anything related to medication. Medication Sheets reviewed for the months of January, February, and March medication was provided to the residents and medication was observed.

Although the allegations may have happened or are 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 was conducted with Jesse Mota Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2