191290642-8-29-2022-28-AS-RORN-CJ2M6M-20220907092008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/29/2022
Date Signed: 08/29/2022 02:01:29 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
08/19/2022 and conducted by Evaluator Joe Katrdzhyan

COMPLAINT CONTROL NUMBER: 28-AS-20220819112330

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: 73	DATE:	08/29/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Executive Director / Jesse Mota		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident is being harassed while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Executive Director / Jesse Mota who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Resident is being harassed while in care."

During today's visit, LPA interviewed the Executive Director, Staff members 1 - 3 (S1 - S3) and Residents 1 - 5 (R1 - R5). Also, Copies of the following documents were obtained and reviewed;

• Resident and Staff Roster • Visitor Log • Notes written by R1 • Physician's Report • Medical notes from Glendale Adventist Medical Center

(Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

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-20220819112330

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: 08/29/2022

NARRATIVE

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The investigation revealed the following;

Allegation: Resident is being harassed while in care. The details of this allegation state that Individual 1 (I1) verbally harasses R1 at the door of R1's room or patio while no one is around, usually between the hours of 7pm and 4am. On intermittent occasions. Visits another resident at the Assisted Living facility. Most recent visit: August 10, 2022, possibly August 15, 2022.

Based on interviews conducted the statements obtained were inconsistent and did not corroborate with this allegation. During the interview of R1, R1 described I1 as a visitor who resides on Mariposa St (near the facility). R1 was not sure if I1 has family or friends that reside at the facility. R1 thinks the alleged incident happened on 8/15/22, around 11:30pm, but was unsure on the exact date. Per R1, there were no witnesses at the time of the alleged incident. R1 confirmed not seeing the face of I1 but overheard laughing in front of R1's door, describing the voice of I1 as a younger female. R1 stated that I1 was overheard saying "you need to leave" which made R1 feel uncomfortable. R1 was guessing that the laughing voice was of I1. R1 has seen I1 prior to the alleged incident outside of the facility, on Mariposa St. After reviewing previous notes written by R1 to facility staff, R1 has listed I1 as the wife of R1's bloodline soul mate. R1 goes on to state in the notes that I1 practiced "Wicca" (modern pagan religion) and I1 has accused R1 of "coveting". I1 would have another person place items in her food and water without her permission.
Interviews conducted of staff confirmed that R1 has a history of hallucinating and making up false stories. Medical notes from Glendale Adventist Medical Center describe R1 as being paranoid and delusional. During today's visit, LPA looked outside the patio area of R1 and observed that the patio is enclosed and only the residents who reside around the patio area have access to the enclosed patio. Based on the information gathered, there is insufficient evidence to support this allegation to be true.

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 and a copy of this report was provided to the Executive Director.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC9099 (FAS) - (06/04)

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