191290642-1-13-2023-28-AS-NMAN-CPP2YQ-20230306164907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:05:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 28-AS-20221219111402

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:	01/13/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Celia Garcia - Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff does not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegations. LPA met with Celia Garcia and informed the purpose of the visit.

LPA conducted physical plant tour at 12:00 PM, requested copies of facility documents relevant to the investigation at 12:10 PM and interviewed additional staff at 1:00 PM.

Regarding the allegation that facility staff does not treat resident with dignity and respect, it was alleged that Administration lets employees gossip cruelly with untrue ideas. LPA's interview with two (2) staff referred to by Resident #1 (R1) on 12/21/22 between 12:45 to 2:00 PM revealed that they never talked against any resident and denied talking or gossiping about R1 at anytime while in the facility. Further, staff also denied talking or interacting with R1 aside from the customary greetings and question if R1 needed any assistance. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4364
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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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