191290642-6-22-2023-28-AS-NGID-CTHVAF-20230707161551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 06/21/2023
Date Signed: 06/22/2023 01:43:39 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 28-AS-20230105122836

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: 109	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Celia Garcia, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident's HVAC system is leaking water into room while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit to deliver final findings. LPA met with the Administrator, explained the reason for the visit and obtained resident and staff roster.

At approximately 10:30 AM, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations.

During the initial visit, conducted on 01/10/23, LPA Panushkina interviewed the Administrator, Assistant Administrator, Maintenance, Maintenance Assistant and six (6) out of ten (10) residents from 12:00pm-3:00pm. LPA also collected documents relevant to the investigation such as Physician Reports, Appraisal Needs and Services Plan, Maintenace Log, etc.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

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-20230105122836

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 06/21/2023

NARRATIVE

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It was alleged that Resident #1 (R1's) Heating Ventilation and Air Conditioning (HVAC) system in room #72 is leaking. To investigate this allegation, LPA conducted an interview with the Administrator, Administrator's Assistant and Maintenance man and was informed that around December 2021, R1's HVAC was not working properly and the facility Maintenance man immediately fixed it. However, right after the HVAC system was fixed, R1 sealed the Air Conditioner (AC) unit with styrofoam cups and did not allow anyone to touch it. In addition, R1 tampered with the AC Unit and requested facility to hire a licensed vendor. Although, the licensed vendor was hired by the facility, R1 refused the entry. Interview with R1 confirmed refusal. LPA was also informed by the Administrator that R1 was provided with an alternative option to move to a different room. Again, that option was turned down four (4) times by R1. LPA conducted visit to five (5) random resident rooms and observed all HVAC system operating properly. Lastly, interviews with six (6) out of ten (10) residents claimed that the facility was doing a good job repairing items that break.

Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023

LIC9099 (FAS) - (06/04)

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