191290642-12-9-2022-28-AS-RORN-CMCMMM-20221222084408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/09/2022
Date Signed: 12/09/2022 04:24:55 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
12/07/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221207113118

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: 89	DATE:	12/09/2022
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Celia Garcia, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility failed to provide a safe environment for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with new Administrator Celia Garcia.

The investigation consisted of: A physical plant inspection of the interior and exterior grounds was conducted. The call light system was tested in 9 rooms. Staff (S1-S6) and residents (R1- R9) were interviewed. A copy of residents (R1 &R2) file documents [Identification and Emergency Information, Preplacement Appraisal, Resident Appraisal, Physician's Report, House Rules, Personal Rights, and Admission Agreement] were obtained. Incident report 12/1/22, Resident Roster, and Employee List were obtained.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022

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-20221207113118

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: 12/09/2022

NARRATIVE

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Allegation: Facility failed to provide a safe environment for resident. It is alleged that resident (R1) threatened to kill resident (R2) on two occasions. The second incident occurred on 12/1/2022 in the dining room with witnesses present. It is also alleged that staff were made aware of the incident, but the issue was not addressed nor actions were taken by Administration to ensure the resident's safety. Based on interviews conducted, residents (R1 & R2) shared a room and had an argument because R2 borrowed R1's socks without permission. Therefore, R1 got very upset and threatened to punch R2. Resident (R1) stated that on several occasions R2 talked in a vulgar way about facility staff, and it got the resident upset. When the sock incident occurred R2 accused R1 of being ungrateful with it's past assistance with getting dressed. The residents had two verbal arguments, one was in the dining room during breakfast time. According to resident witness (R3), R1 verbally attacked R2 by saying it was going to kill the resident. Resident (R1) denied threatening to kill R2, but did state it threatened to punch R2's face. Due to R1's physical disability and mobility issues, it is unlikely R1 could harm R2.

Upon knowledge of the verbal confrontation incident that occurred in the dining room involving residents (R1 & R2), the Assistant Administrator moved resident (R2) out of the shared room the same day. No further incidents have occurred. The physical plant inspection of the facility did not reveal any environment safety issues. A total of nine (9) residents were interviewed. Two (2) out of nine (9) residents stated they do not feel safe at the facility. All staff interviewed stated the facility provides residents a safe environment. Staff stated there have been no safety concerns reported by residents. The main entrance door is locked at 8 pm and any resident that returns to the facility after 8PM must be buzzed in through the front entrance. All the exit doors were inspected and are operational.

Based on interviews conducted the investigation revealed that although the allegation 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 allegation is Unsubstantiated.

Exit interview was conducted with Administrator Celia Garcia. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022

LIC9099 (FAS) - (06/04)

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