191290642-1-3-2023-28-AS-RRAZ-CQTW5V-20230412165947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/03/2023
Date Signed: 01/03/2023 02:49:06 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
12/29/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 28-AS-20221229142520

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:	11:30 AM
MET WITH:	Celia Garcia - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not provide proper medication assistance to residents in care

INVESTIGATION FINDINGS:

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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 11:30 AM, requested copies of facility documents relevant to the investigation at 11:45 AM and interviewed resident and staff between 12:00 PM to 2:00 PM.

It was alleged that Resident #1 (R1) missed night time medication (pain medication) and lunch medication (pain medication and stool softener). LPA's record review today at 11:55 AM revealed that R1 did not miss any routine medication but missed PRN (Pro re nata or commonly known as "as needed") medication. LPA's interview with R1 today at 10:17 AM also revealed that R1 was aware that those were PRN medication and unsure if R1 requested the PRN medication on the day that R1 was not given medication, R1 stated though that R1 had been taking these medication regularly. (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: 01/03/2023

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)

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Control Number 28-AS-20221229142520

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: 01/03/2023

NARRATIVE

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(continued from LIC 9099)

R1 also stated that R1 will call R1's physician to make these medication routine so R1 did not have to request these medication to be given to R1. LPA's interview with Resident #2 (R2) at 1:05 PM also revealed that R2 did not miss medication but only some understandable delay as R2 sometime hang out with other resident's room.

Based on the information gathered during this visit, the allegation is 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: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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