191290642-12-22-2022-28-AS-RORN-CP3LW7-20230215080635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/22/2022
Date Signed: 12/22/2022 09:33:38 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

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210416152412

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: 89	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Office Manager- Cynthia Valdez		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility is in disrepair, broken phone jack.

INVESTIGATION FINDINGS:

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***This licensing report supersedes the complaint investigation report created on 04/28/21. The findings have been changed from SUBSTANTIATED to UNSUBSTANTIATED based on the following***

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 and the findings were discussed.

On 4/22/21, LPA Tony Vasallo initiated a complaint investigation for the allegation listed above. 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.

On 4/28/21. LPA Vasallo conducted a subsequent visit and the investigation consisted of the following: Administrator and S1 were interviewed on 4/22/21. Continuation on 9099-C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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-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: 12/22/2022

NARRATIVE

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Administrator provided Resident #1's (R1) admission agreement and recent rent invoices. A virtual tour was conducted during today's visit and R1 was interviewed.

On today’s visit, LPA Calderon delivered the updated complaint investigation findings.

Regarding the allegation: Facility is in disrepair, broken phone jack. Upon licensee providing further information, the investigation revealed: On April 15, 2021, a technician came to the facility to check the R1's phone line and the technician confirmed the telephone line was operational, however, the phone line was not for internet usage. Based on LPA Vasallo’s interviews conducted on April 22,2021 and April 28,2021 with residents and staff, R1 was offered to relocate to another room. R1 voluntarily moved to a different room that receives internet access. Therefore, the investigation revealed the telephone line in R1 was operational and not in disrepair, however, the phone line did not have internet usage capabilities.

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 Valedez and copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

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