191290642-7-19-2022-28-AS-RORN-CJQMVR-20220929095712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 07/19/2022
Date Signed: 07/19/2022 05:51:16 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
07/11/2022 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20220711170130

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: 72	DATE:	07/19/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jesse Mota, administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff over medicating residents.
Staff not properly supervising residents.
Facility is overcharging resident.
Cigarette smoke is entering resident's room.
Staff threatened resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegations listed above today. During today’s visit, LPA met with administrator Jesse Mota. LPA explained the purpose of today's visit to administrator regarding the above-mentioned allegations.

Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #6 (S6); interviews of residents from residient#1 (R1) through resident #7 (R7); reviewed resident#1’s record reviews, and a facility tour.

LPA obtained copies of the Staff and Resident Rosters; and resident files for resident#1 (R1) with relevant information.

The investigation revealed the following:
(-continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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 3

Control Number 28-AS-20220711170130

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: 07/19/2022

NARRATIVE

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In regard to allegation: “staff over medicating residents," it was alleged that residents are over medicated. One (1) out of seven (7) residents could not corroborate the allegation. Six (6) out of seven (7) residents interviewed which from resident#2 to resident #7 revealed that residents’ medication was properly administered by staff. Six (6) out of six (6) staff interviewed which from staff #1 to staff #6 denied the allegation. LPA reviewed resident#1’s medical record and did not observe resident was over medicated.

In regard to allegation: “staff not properly supervising residents," it was alleged that resident#1’s roommate was naked and grabbed resident, but staff ignored the incident after it was reported. One (1) out of seven (7) residents could not corroborate the allegation. Six (6) out of seven (7) residents interviewed which from resident#2 to resident #7 revealed that residents were not aware of the incident and had never seen that happened at the facility. Six (6) out of six (6) staff interviewed which from staff #1 to staff #6 denied the allegation. Staff interview reviewed that resident#1 has never had a roommate. LPA toured resident#1’s room and observed that staff would check on resident#1 for assistance.

In regard to allegation: “Facility is overcharging resident," it was alleged that facility wanted to increase and charge resident#1’s rent to $3000. One (1) out of seven (7) residents could not corroborate the allegation. Six (6) out of seven (7) residents interviewed which from resident#2 to resident #7 revealed that residents’ rent did not increase to $3000. Six (6) out of six (6) staff interviewed which from staff #1 to staff #6 denied the allegation. Administrator stated that resident’s rent did not increase for the past years and remain the same for this year.

In regard to allegation: “cigarette smoke is entering resident's room," it was alleged that cigarette smoke got into resident#1’s room through the room window. One (1) out of seven (7) residents could not corroborate the allegation. Six (6) out of seven (7) residents interviewed which from resident#2 to resident #7 revealed that residents did not smell cigarette smoke in their rooms. Staff would come to residents’ room to close the window if residents reported of smelling cigarette smoke. Six (6) out of six (6) staff interviewed which from staff #1 to staff #6 denied the allegation. LPA toured resident#1 room and did not smell cigarette smoke or foul smell in the room.

(-continued in LIC 9099 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220711170130

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: 07/19/2022

NARRATIVE

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In regard to allegation: “Staff threatened resident," it was alleged that staff said to resident not to report anything about the facility. One (1) out of seven (7) residents could not corroborate the allegation. Six (6) out of seven (7) residents interviewed which from resident#2 to resident #7 revealed that residents had never been told not to report anything about the facility. Six (6) out of six (6) staff interviewed which from staff #1 to staff #6 denied the allegation.

Although the allegations 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 allegations are UNSUBSTANTIATED.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Administrator. A hard copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC9099 (FAS) - (06/04)

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