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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 10/29/2020
Date Signed: 10/30/2020 04:35:57 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2019 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191215193918
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:POLITA BARNESFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 90DATE:
10/29/2020
UNANNOUNCEDTIME BEGAN:
03:58 PM
MET WITH:Jesse Loera MotaTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff mismanages resident's medications.
Facility staff failed to administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegations above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Jesse Loera Mota, the Assistant Administrator.

During the initial visit on 12/23/19, LPA Chan obtained a copy of the Staff and Resident rosters. LPA randomly selected 10 resident files and requested copies of the physician's report, facesheets, medication record log from October through December 2019. LPA also reviewed six staff files. Interviews were conducted with the Assistant Administrator and Staff #1. Additional interviews with Staff and Residents were conducted on later dates.

(Continue on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
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 3
Control Number 28-AS-20191215193918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: LEISURE VALE RETIREMENT HOTEL
FACILITY NUMBER: 191290642
VISIT DATE: 10/29/2020
NARRATIVE
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In regards to allegation – Facility staff mismanages resident’s medications. It is alleged that Resident #1 (R1) has not been getting refills of the needed medications. Based on interviews with the Med Techs, Resident’s medications are refilled regularly and at least a week prior to the last dosage. Med Techs also stated with Kaiser's patient, they are only able to request refills if they have less than 10 days left of the medications. They stated that the residents have been getting their refills on time and the only time there could be any issues is if they need authorization from the doctor. Per Med Tech, the request for refills are written down with resident's name and medications requested. LPA had obtained the medication refill logs from October through December 2019 and after review of the MAR log, Physician's Order, and refill log, there were some discrepancies observed. The refill requested for one of the medications (Buspirone) for R1 was not listed on the Physician's order nor the MAR log. In addition, the December 2019 MAR log indicated 2 other medications - Prolensa Eyedrops and Famotidine which were not found in the list of medications under the Physician's After Summary report. One of the medication was initialed when it was administered and the other was not marked as given or discontinued. Therefore, there is evidence to show that the medications were not managed properly.

In regards to allegation - Facility staff failed to administer resident's medication as prescribed. Based on records reviewed, it was determined that Resident #1 (R1) medications were not given as prescribed. Per Med Tech, they initial every time they distribute medication. While reviewing the December 2019 MAR log for R1, LPA observed some of the medications were missing initials on various dates and times to indicate that the medication had been administered. Staff interviewed stated that the blanks could possibly be because the Med Tech had forgotten to initial at the time but were given. Additionally, R1's Physician's order dated 12/9/19 had 3 other medications -Cyanocobalamin(Vitamin B-12), Omeprazole Magnesium, and Metronidazole not input or marked on the MAR log, which is an indicator that the medication were not given.

Based on LPA interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Jesse Mota. A copy of this report was emailed for a signature and the Appeal Rights was provided alongside this report.

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20191215193918
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: 10/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2020
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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The licensee shall conduct a staff training on medication documentation to ensure that they are providing residents medication on time. This POC is due on 10/30/20.
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Based on record review, Licensee did not ensure that R1 medications are given daily according to the physician's order which poses an immediate health and safety risk to the residents in care.
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Type A
10/30/2020
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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The licensee shall review R1's medication log to ensure that the medication matches the Physician's order by POC due date 10/30/20.
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Based on record review, licensee did not ensure that the new medications/discontinued medication for R1 were reviewed and added to the MAR log for December 2019, which poses an immediate health and safety risk to the residents in care.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3