191290642-1-7-2021-28-AS-MVAO-BZLPLP-20210330112504

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/07/2021
Date Signed: 01/07/2021 03:21:20 PM

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
12/29/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201229123730

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	POLITA BARNES		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 80	DATE:	01/07/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jesse Mota, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Resident was forced to receive hospice care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza initiated a 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 explained telephonically to receptionist Cynthia Valdez. Administrator Jesse Mota was available shortly after.

The investigation consisted of the following: Staff (S1- S6) and residents (R1- R3) were interviewed. Interviews with residents (R4-R6) were attempted. At 1:30 pm LPA observed 2 hospice residents via FaceTime, both residents were bed bound; appeared to be in poor health. Resident (R5's) Power of Attorney (POA) was interviewed. Hospice agency Administrator was interviewed. Resident (R1's) documents were requested and reviewed. The following items were obtained: Identification and Emergency Information/Face Sheet, Admission Agreement, Physician Report, Resident Appraisal, incident reports, admission agreement, 18 incident reports, Hospice agency contact information, and Physician order for hospice services dated [12/25/20]. In addition, R4-R6 file documents were obtained; including POA contact information
*** See LIC 9099C for continuation of report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

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-20201229123730

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: 01/07/2021

NARRATIVE

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Allegation:" Resident was forced to receive hospice care." Based on interviews conducted and document review the findings revealed that resident (R1's) personal physician referred resident to hospice services on 12/25/20 as a result of decline in health related to pre-existing underlying conditions. Resident (R1) returned to the facility on 12/21/20 after discharge from a Skilled Nursing Facility (SNF). According to all staff interviews there is a total of three (3) residents presently receiving hospice services that were ordered by their physicians. Per all staff, none of the residents are forced to enroll in hospice services. Medical doctors order hospice services and the facility coordinates care with the agencies. Hospice agency Administrator stated that R1 is in need of hospice services due to poor health, and confirmed services were ordered by R1's MD. The physician order was obtained.

Resident (R1) stated that it was not forced to enroll in hospice, and confirmed medical doctor issued order. Residents (R2-R3) stated residents are not forced to enroll into hospice. Power of Attorney (POA) for hospice resident (R5) stated medical doctor discussed hospice service needs, and the facility did not have input into decision to enroll resident to hospice. Per POA, R5 is receiving appropriate care. At 1:30 pm, two (2) facility hospice residents were observed via FaceTime. They were bed-bound and appeared to have poor health. Therefore, the findings indicate that all hospice residents have been enrolled into hospice due to declining health conditions determined by their physicians.

Based upon document review and interviews conducted the findings indicate that, 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.

A telephonic exit interview was conducted with Administrator Jesse Mota. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

LIC9099 (FAS) - (06/04)

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