191290642-12-13-2022-28-AS-RORN-CMZMFV-20230112083458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/13/2022
Date Signed: 12/13/2022 01:12:23 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
12/06/2022 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221206120120

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: 90	DATE:	12/13/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Celia Garcia		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff terminated residents home health care without residents consent

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted an initial complaint visit and investigate the above alleagtion. LPA met with Office Manager, Cynthia Valdez and explained the purpose of the visit. Shortly after, LPA met with Administrator Celia Gracia and assisted the visit.

The investigation consisted of the following: LPA interviewed 5 residents (R2-R6), administrator, assistant administrator and office manager and LVN via phone. LPA also obtained staff and resident roster, copy of R1's Home Health sign in sheet, copy of R1's Wound Care visit progress notes on 11/7/22 and 11/30/22, R1's lab result dated on 11/21/22, R1's discharge order from LA Comfort Home Care dated on 10/27/22

The investigation revealed of the following: In regards to the allegation of "Staff terminated residents home health without residents' consent" LPA interviewed residents and all denied the allegation.

(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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-20221206120120

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: 12/13/2022

NARRATIVE

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All residents reported they are happy living in the facility and they also have no issues with their home health or physical therapy services got terminated by the facility. LPA interviewed the facility staff, they stated that they cannot terminate residents home health or any therapy services without residents' or residents' doctor consent and they have no access to residents home health services as they are not a medical facility. The administrator reported the doctor would notify facility about the home health order but they have no control of that. LPA also reviewed R1's wound care visit notes on 11/30/22 and it indicated that R1's wound has been had great improvement. Wound care services will be on "as needed " status and if patient requires continued to home health services, and has to forward all orders and requests to the R1's primary care physician.

Based on LPA's observations and interviews and documents reviewed, 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)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC9099 (FAS) - (06/04)

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