191290642-12-8-2022-28-AS-TVAO-CNDV38-20230124150420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:49:25 AM

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
12/01/2022 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221201123416

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: 88	DATE:	12/08/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Celia Garcia (Facility Administrator)/S1		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff do not treat resident with respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial complaint visit to investigate the above allegation. LPA met with Celia Garcia and discussed the purpose of today's visit.

During this visit, LPA obtained a copy of the resident roster, staff roster with contact information, interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #3 (R-1 through R-3). LPA reviewed Resident #4 (R-4) file and obtained relevant documentation.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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-20221201123416

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: 12/08/2022

NARRATIVE

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Allegation: Staff do not treat resident with respect. Staff interviews revealed that on 12/01/2022, R-4 became upset when S-3 did not allow R-4 to take the sugar container to R-4's room as the sugar container is used at the dinning room for other residents. Staff interviews revealed that S-3 offered R-4 sugar packets to take to R-4's room instead of taking the sugar container. Staff interviews revealed that R-4 became upset, became verbally aggressive and drove R-4's electric wheelchair towards S-3 and due to this incident the local police department was called. LPA obtained the police department information including the incident number. Resident interviews confirmed the above information and they witnessed this incident. Resident interviews revealed that staff treat residents with respect. Interviews do not corroborate this allegation.

Based on LPA's observations and interviews, investigation revealed: 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 conducted, appeal rights and a copy of this report was provided to Celia Garcia (Facility Administrator)/S1

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC9099 (FAS) - (06/04)

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