191290642-8-25-2022-28-AS-MVAO-CJHNBA-20220922101848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:10:12 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 Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220819104114

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:	08/25/2022
		UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Celia Garcia/Assistant Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not assist resident's bathroom needs in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the 10-day initial complaint visit. LPA met with the Assistant Administrator and explained the purpose of today's visit.

During this investigation, LPA requested the following: a copy of the staff and resident roster, NOC shift staff contact information and staff notes (NOC shift), staff schedule for 08/09/22 through 08/11/22 and visitor policy. LPA interviewed the Assistant Administrator, S-1 and S-2. LPA also interviewed Resident #1 and Resident #3 through Resident #7 (R-1 and R-3 through R-7). Resident #2 (R-2) refused to be interviewed.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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-20220819104114

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: 08/25/2022

NARRATIVE

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Allegation: Staff did not assist resident's bathroom needs in a timely manner. Staff interviews revealed there are (3) staff working during the night shift which includes staff from a registry. Staff also indicated this facility uses (2) different registry agencies. Staff interviews revealed that there is always a staff from this facility along with the staff from the registry. Interviewed staff indicated rounds are conducted every 2 hours and as needed. Interviewed staff indicated they have not had any issues with staff from the registry. In regards to staffing, interviewed staff indicated they have not received any concerns/complaints from anyone in regards to staffing. Interviewed staff indicated this facility has visiting hours of 9AM to 8PM everyday and visitors do not come in after those hours. Per staff interviews, the entrance to the building requires a staff to physically open the door as it is locked through the outside to ensure the health and safety of the residents (doors are unlocked through the inside of the building). Interviewed staff indicated they have not received any concerns/complaints in regards to visitors coming in after visiting hours. (1) of the (7) residents refused to be interviewed (R-2). (6) of (7) resident interviews revealed, they have observed 3 staff working during the night shift and that staff conduct rounds on a consistent basis. (6) of (7) resident interviews revealed that staff meet their needs (including bathroom and incontinence needs) in a timely manner and do not have any concerns in regards to staffing. (6) of (7) residents indicated they have not seen visitors inside this facility after visiting hours. (6) of (7) residents indicated they do not have any concerns/complaints in regards to visitors and that they feel safe at this facility.

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

Exit interview conducted, a copy of this report and appeal rights were provided to the Assistant Administrator

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC9099 (FAS) - (06/04)

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