191290642-4-28-2021-28-AS-RORN-CP3LW8-20230215080637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 04/28/2021
Date Signed: 04/28/2021 03:01:45 PM

Substantiated

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 Tony Vasallo

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: 71	DATE:	04/28/2021
		UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Jesse Mota, administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is in disrepair, broken phone jack

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegation 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, administrator. The initial complaint tele-visit was conducted on 4/22/21.

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 today's visit and R1 was interviewed.

The investigation revealed the following: Staff indicated the phone company visited the facility to repair R1's phone jack in order for R1 to use the internet. The phone company suggested R1 move to another room with a different phone jack. R1 indicated the phone company said the phone jack was not operating and R1 would not be able to use the internet. R1 confirmed he/she is moving to another room. Continued on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

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 5

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: 04/28/2021

NARRATIVE

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Facility provided the invoice from the phone company, but it did not detail the work that was done on the phone jack. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Deficiency is being cited on the attached LIC 9099D.

Exit interview held with Celia Garcia and a copy of the report and appeal rights were emailed for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 04/28/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation : (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Staff and R1 confirmed R1 is moving to a room with a operating phone jack. R1's old room will stay vacant. Therefore, the POC will be cleared since R1 is being moved to another room.
	8 9 10 11 12 13 14	This deficiency was evidenced by the following: Staff and R1 indicated the phone jack in R1's room is not working properly in order for R1 to use internet.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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 Tony Vasallo

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: 71	DATE:	04/28/2021
		UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Jesse Mota, administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is not kept clean, dirty carpet.
Facility staff threatened to evict resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
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9
10
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13

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, today’s complaint investigation was conducted telephonically with Jesse Mota, administrator. The initial complaint tele-visit was conducted on 4/22/21.

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 today's 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 today 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.
Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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: 04/28/2021

NARRATIVE

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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 led 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.

Exit interview held with Celia Garcia and a copy of the report was emailed for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5