191290642-3-29-2022-28-AS-SCOL-CDQLS6-20220422090011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:16:54 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
01/10/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220110105859

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:	01:41 PM
MET WITH:	Jesse Mota - Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not respond to resident's call button in a timely manner

INVESTIGATION FINDINGS:

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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 investigation consisted of the following: On 1/19/22 LPA Flores conducted interview with office manager and requested copies of the following documents staff and resident roster, caregivers' schedule for two months. Assistant administrator will email LPA in-service provide to staff regarding respond to call light. LPA Flores observed call light panels set up next to room #25 and #52 with Assistant administrator no rooms were observed due to COVID isolation guidelines. On 3/29/22 LPA conducted interviews with resident #1,#2,#3,#4,#5,#6,#7, and staff #1,#2,#3,#4,#5,#6. LPA observed and tested call light in bedroom #59, #16,#19.
(CONTINUED LIC9099C)

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)

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Control Number 28-AS-20220110105859

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

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The investigation revealed the following: Regarding allegation: Staff did not respond to resident's call button in a timely manner. It is alleged call light has been on for 2 hours, resident needed assistance putting groceries away. Interviews revealed the following, during interviews with residents 3 out of 7 residents interviewed stated staff respond to call light right away or within 10 minutes. 1 out of 7 resident stated it takes up to 30 minutes to respond. 2 out of 7 residents stated to not use the call light, and 1 out of 7 residents stated call light does not currently work. 3 out of the 7 residents state facility's staff checks on residents at least every two hours and/or call light is used to request assistance and not for emergency use. Interviews with staff revealed 5 out of 6 staff stated staff respond to call light within 30 minutes and 1 out of 6 staff revealed staff check on residents every 2 hours. 3 out of the 6 staff interview stated call light is utilize by the residents for assistance such as giving the TV remote, bringing them water, getting up, or putting on shoes. Administrator stated that for emergencies or PRN medication request residents call the front desk instead of using call light. Facility provided an in-service training regarding call light not working and staff required to check on residents every hour on 3/24/22. Facility posted a sign in the wing were call light is out of order notifying residents of call light not working and that staff will be providing hourly checks.

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)

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