191290642-9-16-2022-28-AS-WSHO-CSXNGL-20230619102715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 09/15/2022
Date Signed: 09/16/2022 04:46:19 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, 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
03/11/2022 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220311143830

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: 74	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator, Jesse Mota		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff harass a resident while in care.

Staff make inappropriate comments towards a resident.

Resident was not accorded with dignity in their relationship with staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (A1: Jesse Mota). LPA/RA spoke to S2 prior to entering the facility to conduct a risk assessment. S2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA Joe Katrdzhyan conducted the unannounced Initial 10-day visit.

The purpose of today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. LPA/RA Ceniceros interviewed (between 10:00 a.m. - 11:00 a.m.) there were seven (7) staff members and eight (8) residents in total. LPA/RA Ceniceros reviewed (between 8:30 a.m. – 9:30 a.m.) the requested documentation (during the initial 10-Day on 03/17/22) - including additional documentation: Admissions Agreement (dated 03/17/21), Emergency I.D. and Information Sheet (dated 07/02/21), Physician’s Reports (dated 01/18/21 & 08/08/22), Resident Appraisals (dated 04/13/21 & 04/08/22), Caregiver Alert List (dated 03/17/22), and Conservatorship Documents (effective 11/30/20) for Resident #1 (R1); Staff and Residents Roster, and Personal Rights In-Service Training on 05/03/21 & 05/04/21.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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-20220311143830

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: 09/15/2022

NARRATIVE

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Regarding Allegation #1: this investigation revealed based on interviews conducted with facility staff members and residents in care corroborated that they have not observed or received reports of a facility staff member sexually harassing or making sexual advances or using hand gestures of a sexual nature towards a resident in care nor shaming a resident on their dress attire.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff harass a resident while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted with facility staff members and residents in care corroborated that they have not observed or witnessed a facility staff member shaming them in the presence of a friend due to their sexual preference or making inappropriate sexual or derogatory comments towards a resident or making a resident feel uncomfortable based on their sexual and gender identity. Former Staff #1 (S1: Med Tech P.M.) provided Resident #1 with a cell number should the resident need to contact a night-shift staff member; as the front desk phone closes after hours at 11:00 p.m. but will transfer the calls to the cell phone manned by the night-shift personnel.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff make inappropriate comments towards a resident is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed based on interviews conducted with facility staff members and residents in care corroborated that the facility is supportive to the residents with respect to their sexual and gender identity and residents feel comfortable to freely express themselves. There were no witnesses to the alleged incident involving Staff #1 (S1: Caregiver) who provided a written statement to which S1 denied any sexual advances. Since the facility's call light system was out R1 was telling S1 about a life story and what R1's gone through, been suicidal and going through depression. Staff #1 didn’t mean harm and said if you need to talk, gave R1 a hug and the phone number; of which, the NOC shift was carrying around a cell phone with them. There was no sexual embrace. it was more of a support for R1 having opened up to S1 just in case the resident had bad thoughts of hurting oneself. At the time, S1 was working the night shift (11pm – 7am). Staff #1 is no longer working at the facility, effective 07/11/2022. LPA/RA Ceniceros

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220311143830

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: 09/15/2022

NARRATIVE

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reviewed the facility's Personal Rights In-Service Training for staff members; and, it was conducted on 05/03/21 and 05/04/21 from 3:00 p.m. to 4:00 p.m.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Resident was not accorded with dignity in their relationship with staff is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator (Jesse Mota).

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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