<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 02/09/2023
Date Signed: 02/09/2023 09:44:46 AM

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
04/16/2021 and conducted by Evaluator Ashley Calderon
COMPLAINT CONTROL NUMBER: 28-AS-20210416152412
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:JESSE MOTAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(818) 244-2323
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 88DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Office Manager- Cynthia ValdezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair, broken phone jack.
Facility is not kept clean, dirty carpet.
Facility staff threatened to evict resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
***This licensing report supersedes the complaint investigation report created on 04/28/21 and 12/22/22 due to pertinent information missing from the previous reports and the finding was changed for one allegation.***

Licensing Program Analyst (LPA) Calderon conducted a visit to supersede the report dated 4/28/21 and 12/22/22 for the allegations listed above. LPA Calderon met with Office Manager Cynthia Valdez and explained the purpose of today's visit. The investigation consisted of the following:

On 4/22/21 Licensing Program Analyst (LPA) Vasallo 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, complaint investigation was conducted telephonically with Jesse Mota, administrator. A telephone interview was conducted with administrator and Staff #1 (S1). Administrator was also asked to provide Resident #1's (R1) admission agreement and recent rent statement.
Continuation on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20210416152412
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: 02/09/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 4/28/22 Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, complaint investigation was conducted telephonically with Jesse Mota, administrator.

The investigation consisted of the following: Administrator and S1 were interviewed on 4/22/21. Administrator provided Resident #1's (R1) admission agreement and recent rent invoices. A virtual tour was conducted during visit and R1 was interviewed.

Allegation: Facility is not kept clean, dirty carpet. It’s alleged R1’s room has dirty carpet. Virtual tour conducted did not corroborate the allegation. R1 was interviewed and stated it seemed old. Carpet is a dark brown color and did not seem visibly dirty or stained. R1 was offered another room and will be moving to another room with brand new floors. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Facility staff threatened to evict resident. Allegedly R1 has been threatened with eviction. Staff interviewed deny the allegation. Staff indicated that R1 was recently given an invoice with the past due balances due for the past 3 months. R1 indicated he/she was not threatened but told that if the balances are not paid it can lead to an eviction. R1 confirmed he/she has not paid the full rent for the past 3 months. Title 22 Regulations and the facility admission agreement indicate residents can be evicted for nonpayment of basic services. Based on the information obtained, the allegation is Unsubstantiated. 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 visit was conducted by LPA Vasallo on 4/28/21 regarding allegation: Facility is in disrepair, broken phone jack. Based on LPA Vasallo’s virtual inspection of the facility and interviews it was revealed that the phone jack in room 62 was not operating and R1 would not be able to use the internet. Based on this information, LPA Vasallo delivered a substantiated finding. (Continuation on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210416152412
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: 02/09/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 12/22/22 Licensing Program Analyst (LPA) Ashley Calderon conducted a subsequent complaint visit and met with Office Manager Cynthia Valdez. The purpose of the visit was to redeliver complaint investigation findings for allegation: Facility is in disrepair, broken phone jack. LPA Calderon delivered the updated complaint investigation findings that were changed from Substantiated to Unsubstantiated.

Regarding the allegation: Facility is in disrepair, broken phone jack. Based on interviews conducted with resident and staff on 4/22/21 and 4/28/21, the following was revealed: the resident in question never previously had a telephone and/or phone service connected to the phone line in room 62 so it could not be clearly determined whether or not the phone jack would work properly and/or it could not be determined if the phone jack in question was powerful enough for internet usage. During the virtual visit on April 28,2021, staff was requested to connect a phone to the jack in room 62 to confirm that it was working, however staff was unable to because the phone line had never been connected nor a phone number issued to that particular line. After review of the admission agreement, phone service is addressed and the agreement states in part, “A private telephone may be installed at the Resident’s expense, providing existing connections are utilized.” Additionally, the residents have access to a working telephone at the facility if needed. The facility made arrangements for R1 to voluntarily move to a different room that receives internet access. Since Title 22 regulations don’t specifically address internet access for residents and the resident in question confirmed their voluntary move to another room, the allegation is unsubstantiated.



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 above allegations are UNSUBSTANTIATED. No deficiencies were noted on today’s visit per California Code of Regulations Title 22.

An exit interview was conducted with Office Manager Cynthia Valdez a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3