191290642-10-25-2022-28-AS-MVAO-CL2VQ5-20221110153745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 10/25/2022
Date Signed: 10/25/2022 03:04:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/18/2022 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221018101958

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: 77	DATE:	10/25/2022
		UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Jesse Mota		TIME COMPLETED:	03:09 PM

ALLEGATION(S):

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Facility staff do not provide consistent tranportation services to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Jesse Mota (Administrator) and explained the purpose of the visit.
During today's visit, LPA obtained/reviewed a copy of the Staff/Resident Rosters, transportation Log for month of October, Resident #1's (R1) records, and admission agreement. LPA interviewed Administrator and Staff #1 - #3 in the conference room, and Resident #1 - #9 in the conference room.

Regarding Allegation: Facility staff do not provide consistent transportation services to residents. It is alleged that resident #1 (R1) cannot rely on staff to take R1 to doctor’s appointments and other required service appointments because the transportation service at the facility is inconsistent. The administrator stated that the facility provides transportation services as outlined in the admission agreement which is on first come first serve basis and now his office staff and himself are driving residents to their appointments due to lack of driver. Admission Agreement states that transportation is available up to 2 times a week within 7-mile radius and should be reserved at least a week in advanced. (CONTINUED ON 809C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

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-20221018101958

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 10/25/2022

NARRATIVE

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Administrator and 3 of 3 staff denied the allegations. 8/9 residents could not collaborate the allegations. R1 stated he has never reserved or utilized transportation provided by facility because R1 prefers personal attendant like R1 had when receiving IHSS. Administrator and 3 of 3 staff responsible for arranging and providing transportation stated that R1 has never asked for, used or reserved transportation from facility in the time he has lived here.

Based on LPA's observations, record review and interviews, investigation revealed: Although the allegations may have happened or is 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 with Jesse Mota and a copy of this report will be emailed due to printer issues.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC9099 (FAS) - (06/04)

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