191290642-4-11-2023-28-AS-TVAO-CQSN4C-20230411100744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 02/13/2023
Date Signed: 04/11/2023 10:07:44 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
04/07/2021 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210407135903

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: 87	DATE:	02/13/2023
		UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Administrator Celia Garcia		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care
Staff not checking on resident

INVESTIGATION FINDINGS:

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This is a corrected verison of previous complaint report dated 02/13/2023. Verbiage was corrected on LIC 9099. Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannouced subsequent complaint visit stemming from initial 10-day complaint visit dated 04/12/2021, to investigate the above allegation. The purpose of the visit was discussed with Administrator Celia Garcia.

The investigation consisted of the following: A tour of the interior and exterior physical plant was conducted at 10:24 am. Staff #1 through Staff # 4 (S1 – S4) and Resident #1 through Resident #6 (R1-R6) were interviewed. Resident #1 (R1's) Resident Appraisal, R1's Physican's Report, R1's hospital discharge documents, LIC 624 for R1,Incontinent Check and Care log, LIC 500 Personnel Report, and Resident roster were reviewed and obtained.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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-20210407135903

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 02/13/2023

NARRATIVE

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Allegation: Resident sustained pressure injury while in care. It is alleged that R1 received a pressure wound on his/her coccyx while in care on or around 04/04/2021. R1 stated he/she “I am able to put my own catheter in and out but the staff didn’t help me that day, so I was sitting in my own pee and got a sore on my butt.” According to four (4) out of four staff interviewed, all staff deny this allegation. S2 stated “If we’re changing a resident and see something, we report it right away.” According to and five (5) out of six (6) residents interviewed, residents deny ever experiencing or to have witnessed a pressure injury while in care. LPA reviewed R1’s hospital discharge documents dated 04/22/2021, LIC 624 from March of 2021 to May of 2021 and facility incident/observations log from January 2020 to December of 2022. Based on records review and interviews conducted, LPA could not find any evidence to support this allegation.

Allegation: Staff not checking on resident. It is alleged that staff did not check on R1 which caused R1 to be left soiled all night. Allegedly on 04/06/2021, R1 awoke to feces all in their diaper and back. According to four (4) out of four staff interviewed, staff deny this allegation. S1 stated “Due to R1’s past accusations, we require 2 staff to change R1 but R1 has requested no one touch him/her while he/she needs changing, because he/she can do it himself/herself.” LPA reviewed Incontinent Check and Care log for R1 from 03/27/21 to 04/23/21. On 04/06/21, from 12am to 6am, LPA verified that staff assisted R1 in incontinent check and care. At 12:41 pm LPA went into a random room(#27) and pulled the emergency call cord to establish staff response time. Staff arrived at 12:42 pm to clear the emergency response call. Based on records review and interviews conducted, LPA could not find any evidence to support this allegation.

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.

Exit interview conducted with Administrator Celia Garcia. A copy of the report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC9099 (FAS) - (06/04)

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