191290642-10-4-2022-28-AS-LHIS-CLMULF-20221129144039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 10/04/2022
Date Signed: 10/04/2022 04:10:24 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
10/03/2022 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221003100444

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:	10/04/2022
		UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Jesse Mota		TIME COMPLETED:	04:24 PM

ALLEGATION(S):

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Staff are not properly maintaining a resident's room while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPAs) Alberto Lopez and Ashley Calderon conducted an unannounced complaint investigation regarding the above stated allegation. LPAs met with Assistant Administrator Celia Garcia and Administrator Jesse Mota, and explained the reason for the visit.

The investigation consisted of the following:
LPAs obtained copies of Staff & Resident Rosters. LPA reviewed the Personnel Report and interviewed the assistant Administrator, Administrator 5 Staff, and 8 Residents.

The investigation revealed the following:
Allegation – Staff are not properly maintaining a resident's room while in care. LPAs took tour of 8 random rooms #59 #63 #66 #71 #88 #214 #82 #79 LPAs observed 7/8 rooms clean and one room was clean not due to resident not allowing cleaning staff to enter. Assistant Administrator, (CONT ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

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-20221003100444

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: 10/04/2022

NARRATIVE

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Administrator and 5/5 staff did not collaborate the allegations, 7/8 residents stated that their rooms are clean regularly and did not collaborate the allegations.

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.

An exit interview was conducted with the Administrator. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

LIC9099 (FAS) - (06/04)

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