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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/01/2022
Date Signed: 12/01/2022 01:12:38 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
11/02/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221102110448
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:JESSE MOTAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 78DATE:
12/01/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Assistant Administrator Nilda MercadoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff threatened resident.
Illegal eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint investigation to deliver findings regarding the above stated allegations. LPA was greeted by Assistant Administrator Nilda Mercado. Shortly thereafter current Administrator Celia Garcia.
The initial visit was conducted on 11/09/2022 which included the following:
LPAs obtained copies of Staff & Resident Rosters. LPA reviewed the Personnel Report and interviewed the Administrator and Office Manager at 1:30 PM to 2:15 PM.
LPA reviewed Resident R 1's file and various documents were submitted from Resident R 1's file.
Resident R 1 was interviewed at 2:45 PM.
Regional Director was interviewed telephonically at 3:00 PM.
In regards to the allegation Illegal eviction, based on interviews conducted and information gathered, Resident R1 stated that upon admission 09/08/2022 he was not with his dog which he stated is a service dog to assist for mobility.
Stated he brought the dog 4 days later. Stated that facility never threatened him with eviction and that he
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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 2
Control Number 28-AS-20221102110448
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: 12/01/2022
NARRATIVE
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was the one who had asked staff for a letter of eviction.
Interview with Staff who stated that R 1 never discussed a service dog. Stated that the facility did not issue any eviction notice to R1.
Also stated that there was never a mention of eviction to R1.
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.
In regards to the allegation Staff threatened resident, based on interviews conducted and information gathered staff interviewed stated that at admission a service dog was never discussed. Stated that the dog was brought in without the facility knowing 6 days later.
Stated that In House rules no pets.
Staff stated they offered reduced rent to help house dog elsewhere and after many efforts told R1 they would have to call police if not removed.
Documentation form Assisted Living Waiver for R 1 dated 02/24/2022 have no mention of a service dog.
Staff stated that since 09/14/2022 R 1 had been told no pets allowed.
Assessment tool by Home Health agency dated 02/28/2022 has no mention of service dog.
Physician's Report dated 10/11/2022 has no mention of a service dog to provide assistance.
Interview with R1 who stated he felt harassed because facility asked him numerous times to remove dog.
Did confirm facility did offer reduced rent to help him out .
It should be noted police were never called.
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.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2