191290642-3-3-2023-28-AS-RORN-CPQVSE-20230308154124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 12/21/2022
Date Signed: 03/03/2023 08:51:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/29/2022 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221129083828

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: 6	DATE:	12/21/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Celia Garcia		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff allowed use of equipment which presented a hazard to resident.
Facility staff force fed resident medicine.
Facility staff did not ensure resident was fed dinner.
Facility staff prevented resident from using call button.
Facility staff did not meet resident's incontinence care needs.

INVESTIGATION FINDINGS:

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********This is an amended version of the original report created on 12/21/2022. This report is being amended to remove confidential statements and information. No other changes have been made to the report. *********

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit regarding the above allegations. LPA met with Office Manager, Cynthia Valdez and discussed the purpose of the visit. LPA met with the Administrator, Celia Garcia at 10:25am and explained the purpose of the visit.

During the initial visit conducted by LPA Pena on 12/07/2022, LPA interviewed Staff #1-Staff #5 (S1-5) in person and Staff #6 (S6) telephonically, Resident #2-11 (R2-11), attempted to interview Resident #1 (R1) 2x and Staff #7-Staff #8 (S7-8). LPA obtained copies of the staff/resident roster, and requested copies of Resident (R1's) file documents, Medication Administration Record (MAR) for the month of Nov. 2022, Client/Resident Personal Property and Valuables, Face Sheet/ID Emergency Contact, Physician Report, Preplacement Appraisal, Resident Appraisal, Appraisal Needs and Services Plan, and Assisted Living Waiver (ALW) Program Individual Service Plan (ISP). LPA also obtained and reviewed photos and videos.

During today's visit, LPA interviewed Resident #1, telephonically interviewed Staff #7 (S7), Staff #8 (S8) telephonically interviewed on 12/08/2022, obtained R1's doctor medication order/instruction, incontinence care and check log (Oct.-Nov. 2022), Health Care equipment delivery/service report. *****REPORT CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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 6

Control Number 28-AS-20221129083828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 12/21/2022

NARRATIVE

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ALLEGATION: Facility staff allowed use of equipment which presented a hazard to resident. It was alleged that a resident's wheelchair was "ruined" (broken) and it could have injured the resident. And no one reported the broken wheelchair to the resident's family. Interviews with S1-S7 revealed that they were not aware and had not seen the broken R1's wheelchair. All (7) staff stated that it was working properly and did not see it broken during their last shift. S8 stated that he did not know about the broken armrest because none of the staff reported it According to S8 and S1, after asking around, none of the staff knew about what happened to the resident's wheelchair. S1-S7 stated that if there is a broken equipment in the facility, they report it right away to the Administrator or their Manager to avoid causing harm to the residents. And they have not seen any residents using a broken wheelchair. Interviews with R4-R11 revealed that they have not had an experience using a broken equipment. R2-R11 stated that they have not seen any resident using a broken equipment and that the staff will not allow the residents to use a broken equipment. Records reviewed and interviews revealed that the alleged broken wheelchair is not the facility's property. Based on interviews conducted with residents and staff, observation and document review, there was not enough supportive evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

*****REPORT CONTINUED ON LIC9099-C*******

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 28-AS-20221129083828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 12/21/2022

NARRATIVE

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ALLEGATION: Facility staff did not ensure resident was fed dinner. It is alleged that dinner had been left on a tray in the resident's room and out of resident's reach. S1-S8 denied the allegation and stated that food is taken to residents’ room if they request it or if they cannot go to the dining area. S1 stated that caregivers feed residents if needed. And if residents are sleeping, caregivers don't normally wake them but will constantly check to see if they are ready to eat. S1 indicated that sometimes R1 refuses to eat. S1 indicated that caregivers will leave food there for a while and come back later to check if R1 wants to eat. R1 stated that she does not like her meal or not hungry sometimes. (7) staff stated that they have not heard of any complaints about not ensuring resident was fed dinner. All staff stated that if a resident does not want to eat, they leave the food in the room and come back to check if they are ready to eat. S3 stated that R1 has good/bad days where she eats small bites sometimes or will eat the entire meal at times. R2-R11 stated that the staff ensure that they are fed. If they cannot go down in the dining room to eat, staff will call or check on them. If they are sick and cannot go, the food is delivered to their room. Based on records review, statements and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

*****REPORT CONTINUED ON LIC9099-C*******

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20221129083828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 12/21/2022

NARRATIVE

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ALLEGATION: Facility staff force fed resident medicine. It is alleged that R1 was complaining of pain and requested Tylenol and observed a staff used a spoon to forcefully "shove" the medicine into resident's mouth. Interviews conducted with S1-S8 revealed that none of the staff had done it or will do it to the residents because that is not a proper way of doing it. All staff interviewed denied doing it or seeing staff forcing residents to take their medications, and/or shoving the medications into the residents’ mouth. S1-S8 indicated that residents are provided their medications in a small cup, and residents take them themselves. Staff protocol is to ensure the medications are taken in front of staff, and if a resident refuses, it is documented. S1 stated that R1 never reported medications being shoved into her mouth. S5 denied the allegation and stated that the allegation did not happen. S3 and S5 stated that R1 has a history of refusing to take medication. R1 stated that she did not feel like taking her medication sometimes. R2-R11 stated that no staff forced them to take their medication, they all willingly take it. R2-R11 also indicated that they have not seen any staff forced medication to other residents. LPA reviewed MAR reports; medication refusal by R1 was noted. Based on interviews conducted with residents and staff and document review, there was not enough supportive evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

*****REPORT CONTINUED ON LIC9099-C*******

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 28-AS-20221129083828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 12/21/2022

NARRATIVE

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ALLEGATION: Facility staff did not meet resident's incontinence care needs. It is alleged that when changing the resident's diaper, a staff member did not dry the resident after wiping. R1 stated that the staff checks on residents regularly and assist with diaper changing all the time. S1-S2 stated that the facility's protocol is to do a 2-hour check for anybody who has incontinence needs. S1-S8 stated that the facility has a log for the residents 2-hour checks. S1 and S8 indicated that they provide in-service training to the staff. According to staff interviews, they do their rounds every 2 hours and check/change the diapers of those with incontinence needs. They would change their diapers more often if needed. They also remind residents to press the call button for assistance. Other staff have not heard or seen R1 or other residents being left in soiled diapers for long periods of time. R2-R11 stated that staff are caring and give them assistance when needed. Some residents wear diapers, but they do it themselves. But if they need assistance if they're sick, they just use the call button, and a staff will assist them. Based on records review, statements and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

*****REPORT CONTINUED ON LIC9099-C*******

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20221129083828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 12/21/2022

NARRATIVE

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ALLEGATION: Facility staff prevented resident from using call button. It is alleged that someone had moved the resident’s call button to the foot of her bed where the resident could not reach it. R1 stated that she can use the pull string attached to the call button with no problem at all. R1 indicated that staff assists her when she calls. S1 stated that staff checks R1 periodically and if the call button is out of R1's reach, staff put it next to her. (4) staff stated that when they change her diaper, that would only be the time that the call button will be moved, but caregivers put it back next to her. All staff stated that the call button is not being moved away from R1 intentionally. S1 and S8 indicated that in-service training regarding personal rights which includes putting the call button back close to the residents is provided to the staff on a regular basis. Based on records review, statements and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview, a copy of this report and Appeals Rights were provided to the Facility Administrator, Celia Garcia.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC9099 (FAS) - (06/04)

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