191290642-10-21-2022-28-AS-MVAO-CL72C7-20221114161618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:26:49 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
10/18/2022 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221018083105

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:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Simonette Alanes (Activities Director)		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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The facility fails to provide appropriate medical care and services to the residents in need.
The facility fails to provide healthy meals for the residents in special diets.
The facility fails to provide supportive services to assist the mobility of the unstable and disable residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Simonette Alanes (Activities Director) and explained the purpose of the visit. A short time later Jesse Mota (Administrator) arrived to the facility and assisted with the investigation.

During today's visit, LPA obtained/reviewed a copy of the Staff/Resident Rosters, Food Menu, Resident #1's (R#1) records, interviewed Staff #1 in the conference room, interviewed Resident #1 in the conference room and toured the kitchen with Staff #1.

In regards to the allegation: The facility fails to provide appropriate medical care and services to the residents in need. Per interview with Staff #1, R#1 make own medical appointments and provide own transportation to seek medical care. Per interview with R#1, R#1 stated that R#1 does not expect any type of medical services from the facility as R#1 wants to acquire assistants from IHSS (In Home Supportive Service) which R#1 is not receiving. Continue to LIC9099C......

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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-20221018083105

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: 10/21/2022

NARRATIVE

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There is no documentation indicating R#1 qualifying or receiving IHSS services. Based on R#1's Physician's Report and Resident Appraisal, R#1 is ambulatory and capable of self care. Per allegation details, R#1 was indicated the have had a stroke. Physician's Report for R#1 did not indicate a history of stroke.

In regards to the allegation: The facility fails to provide healthy meals for the residents in special diets. Interview with Staff #1 indicate R#1 is not on a special diet. R#1's Physician's Report does not indicate R#1 requires a special diet. LPA reviewed the food menu and toured the kitchen and observed a healthy selection of foods.

In regards to the allegation: The facility fails to provide supportive services to assist the mobility of the unstable and disable residents. Per Physician's Report, R#1 is ambulatory and is not diagnosed with any type of instability or physical disability. Interview with Staff #1 indicate R#1 is ambulatory and does not require supportive services to assist with mobility. LPA observed R#1 to be mobile and ambulatory.

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 provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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