191290642-1-3-2023-28-AS-NMAN-CQ5MJ8-20230321093844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/03/2023
Date Signed: 01/03/2023 02:46:05 PM

Unfounded

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
12/28/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 28-AS-20221228130332

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:	01/03/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Celia Garcia - Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident is being threatened while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA met with the administrator Celia Garcia and explained the reason for the visit.

LPA conducted physical plant tour at 9:20 AM, requested copies of facility documents relevant to the investigation at 9:45 AM and interviewed resident and staff between 10:00 AM to 11:00 AM. It was alleged that staff and resident are plotting to give Resident #1 (R1) a knock out drug that makes R1 appear dead. LPA's interview with R1 today at 10:17 AM, revealed that it was not a complaint but a theory that pertains to an old ex-staff and happened years ago. Based on the information gathered during this visit, the allegation is deemed unfounded. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. Copy of this report issued.

Unfounded

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: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

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 1