191290642-12-12-2022-28-AS-TVAO-CMAV59-20221220150734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/12/2022
Date Signed: 12/12/2022 01:53:03 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
12/17/2020 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201217164838

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	POLITA BARNES		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 88	DATE:	12/12/2022
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Administrator Celia Garcia		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings.
Resident's beverage is contaminated.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez and Licensing Program Manager (LPM) Tony Vasallo conducted an unannounced subsequent complaint visit to investigate the allegations listed above. LPA Gonzalez conducted initial visit in 12-24-2020.

The investigation consisted of the following: Copy of staff and resident roster was obtained, eight (8) residents were interviewed, five (5) staff were interviewed, tour of kitchen and food supply were toured at 12:15 PM during lunchtime.

The investigation revealed the following regarding staff not safeguarding resident's personal belongings: Three (3) out of eight (8) residents recall some items missing from their room at one time or another but could not recall time or date of incident; the items allegedly missing were of nominal value. Five (5) out of the five staff deny witnessing or taking residents personal belongings. Staff alleges they assist residents when they notify them that they misplaced or are missing items from their room. CONT ON 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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-20201217164838

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: 12/12/2022

NARRATIVE

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Staff alleges most time residents misplace items or forget where they place it. Staff stated most items misplaced are found in residents room or in the facility "Lost and Found" box. Based on information obtained, the allegation is unsubstantiated.

Regarding allegation; Resident's beverage is contaminated; Eight (8) out of the eight (8) residents interviewed deny beverages being contaminated and deny becoming ill after consuming beverages served at facility. Five (5) out of five (5) staff deny adding anything to beverages as to contaminate the beverages. LPA and LPM conducted a tour of the kitchen, walk in freezer, inspected the refrigerator, and walk in pantry. LPA and LPM did not observe anything out of the ordinary.

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. Exit interview held, and a copy of this report will be provided via email due to printer issues.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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