191290642-1-17-2023-28-AS-MVAO-CPHRWH-20230301122312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:37:30 PM

Substantiated

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
01/12/2023 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230112085809

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	CELIA GARCIA		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 91	DATE:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nilda Mercado / Business Office Manager		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff not providing medications as prescribed.

INVESTIGATION FINDINGS:

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On 01/17/2023 Licensing Program Analyst (LPA) Troy Agard conducted an initial complaint investigation at the above facility to address the following allegation. LPA Agard met with Nilda Mercado, Business Office Manager and explained the purpose of this visit was to deliver findings for this complaint.

The investigation consisted of the following: LPA toured the physical plant. Areas inspected included the kitchen and dining room, resident bedrooms, resident bathrooms, and outdoor areas. There are no bodies of water present in the facility at this time. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA requested the following records: 1) staff roster, 2) resident roster, 3) medication administration records for R1, 4) physician report for R1. All records were received at the time of visit.

cont on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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 3

Control Number 28-AS-20230112085809

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: 01/17/2023

NARRATIVE

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The investigation revealed the following…Regarding the allegation: Staff not providing medications as prescribed. It’s being alleged that medications are not being given correctly. LPA attempted to interview 4 out of 37 staff in total. 2 out of 3 confirmed the allegation. 1 staff was unavailable for an interview. S1 states, “I don’t know of any medication errors, and I haven’t heard anything.” S2 states, “some of the staff and residents were complaining about the agency staff giving meds late. Some people complained that they were not getting their medication timely from the agency staff.” S3 states, “there haven’t been any errors that I’m aware of. Just complaints from residents that their meds were given late. Even I had a lot of complaints about them because the residents wanted me to explain what happened and why their medication was late. I told them I would let the Administrator know about their concerns.”

During interviews with the residents, LPA attempted interviews with 9 out of 91 residents in total. 1 resident was unavailable for an interview. 5 out of 8 confirmed the allegation. R1 states, “many nights my meds are incorrect. W1 came to me with a cup filled with pills. I informed them they were missing my psych meds. I asked them to give me the correct meds.” R4 states, “It has been crazy lately. They have been trying out all these new Med Techs. Last week, I called for a pain medication at 8am, then again at 11am and by 12 noon I had to come down. I scolded them for not given me my meds. W1 gave me the cup with meds but once I got back to my room, I saw that the pain med wasn’t there.” R5 states, “I have been receiving my morning pills late. One day, when I came to get my meds, it was 1pm. Another time, there was no med tech present and this was the middle of the day. Another time I waited 3 hours for my dinner meds.” R6 states, “sometimes they are late giving the medication and they don’t give me the correct medication especially the ones that don’t work here regularly.” R7 states, “sometimes they give them late. I had them 3 or 4 hours late. They don’t have enough staff to be able to do it all.”

During a record review, LPA reviewed the Medication Administration Records (MAR). LPA observed missing signatures for R1 and R5. LPA observed medication missed for R9 on 01/13/2023. R9 was not observed to be hospitalized or out on a visit.

Based on the interviews with staff, residents and a record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D.

An exit interview was conducted, and a hard copy was provided with appeal rights.
See LIC 9009-D on the next page

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230112085809

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/16/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Facility will develop a plan to ensure residents are receiving their medication timely and correctly. The plan must be submitted to LPA Agard via email or fax by POC due day.
	8 9 10 11 12 13 14	based on interviews and record review medication is not being given as prescribed. This poses a health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

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