191290642-1-13-2023-28-AS-NMAN-CPNTLD-20230306134921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:03:28 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
12/15/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 28-AS-20221215124452

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:	08:54 AM
MET WITH:	Celia Garcia - Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings

Staff does not ensure resident receives mail unopened

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 9:15 AM, requested copies of facility documents relevant to the investigation at 9:40 AM and interviewed additional staff at 11:00 AM.

Regarding the allegation that staff did not safeguard resident's personal belongings, it was alleged that Resident #2 (R2) brought Resident #1 (R1)'s small package to R1's room instead of the staff. LPA's interview with R2 on 12/21/22 at 10:45 AM, revealed that R2 brought the small package to R1 voluntarily without anyone telling R2 to do it and R2 did only because R2 knew R1 and thought that R2 was doing R1 a favor. LPA's interview with staff on 12/21/22 at 11:00 AM also revealed that no staff instructed R2 to deliver anything to R1 at any time.

(continued on LIC 9099-C)

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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Control Number 28-AS-20221215124452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 01/13/2023

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that staff does not ensure resident receives mail unopened, it was alleged that a staff went through R1's grocery and received a package that had been opened. LPA's observation today at around 11:33 AM revealed that grocery bags are delivered in front of the reception area and delivered to the respective residents within minutes. LPA's interview today with Staff #1 (S1) at 11:00 AM also revealed that no one has gone through anyone's grocery bags and denied going through R1's grocery bags as S1 had no reason to, aside from the fact that there were many of them being delivered all day every day. LPA's observation on prior visit on 12/21/22 at around 11:00 AM to the photo provided by R1 revealed that the package was not opened, the side tape was broken but did not look opened at all as the tape on the top of the box was fully intact.

Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

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

LIC9099 (FAS) - (06/04)

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