191290642-2-13-2021-28-AS-MVAO-BZDTBJ-20210323143513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 02/11/2021
Date Signed: 02/13/2021 06:32:37 AM

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
06/22/2020 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200622085833

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: 73	DATE:	02/11/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jesse Mota		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff are hiding resident's medication in food.
Facility staff gave false information to resident's physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Jesse Mota.

The initial investigation was conducted on 06/30/20. On 06/30/20, at approximately 1:00 P.M, LPA requested documentation relevant to this investigation.

During the course of this investigation, LPA Irra interviewed Assistant Administrators, Staff #1 through Staff #11 (S-1 through S-11). Note: LPA attempted to interview S-5 and S-6. S-5 and S-6 did not return LPA’s call. LPA also interviewed Resident #1 through Resident #7 (R-1 through R-7).

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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-20200622085833

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: 02/11/2021

NARRATIVE

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Allegation: Facility staff are hiding resident's medication in food.

Staff interviews revealed that staff are not hiding resident’s medication in food. Interviewed staff indicated they have not observed nor witness any staff hiding resident’s medication in food. Interviewed Staff indicated they are trained in Mandated Reporting and Resident Rights. Interviewed staff indicated they have not received any concerns/complaints from Residents regarding to staff hiding resident’s medication in food. Interviewed staff indicated Med Tech administer all medication and log the disbursement on a Medication Administration Record (MAR). Six (6) out of the seven (7) interviewed Residents indicated their medication is not hidden in their food. Interviewed Residents indicated the Med Tech administer their medication. Interviewed Residents indicated they have not observed nor heard Residents complaining about medication being hidden in the food. Staff and Resident interviews do not corroborate this allegation.

Allegation: Facility staff gave false information to resident's physician

Interviewed Staff indicated that they are not aware of staff providing false information to resident’s physician. Interviewed Staff indicated they have not received any complaints/concerns from Residents regarding staff providing false information to the residents’ physician. Six (6) out of the seven (7) interviewed Residents indicated they have not heard nor witness staff providing false information to their physicians. Staff and Resident interviews do not corroborate this allegation.

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.

A telephonic exit interview was conducted with the Facility Administrator, a hard copy was provided via e-mail for signature and Appeal Rights were provided

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC9099 (FAS) - (06/04)

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