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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 06/21/2023
Date Signed: 06/21/2023 03:22:28 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, 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
05/09/2023 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20230509161340
FACILITY NAME:LEISURE VALE RETIREMENT HOTELFACILITY NUMBER:
191290642
ADMINISTRATOR:CELIA GARCIAFACILITY TYPE:
740
ADDRESS:413 E. CYPRESSTELEPHONE:
(323) 697-2248
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Celia Garcia, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident fell sustaining injury due to staff neglect
Facility carpet is in disrepair
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 05/15/23, interviews and record review were made. Between 10:50am – 12:00pm, LPA interviewed the Business Office Director, Maintenance staff, two (2) caregivers, and thirteen (13) out of fourteen (14) residents. At 12:05pm, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Appraisal Needs and Services Plan, President Council Meeting Agenda, etc., relevant to the investigation.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 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)
Page: 1 of 3
Control Number 31-AS-20230509161340
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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During todays visit, LPA conducted an interview with Resident #1 (R1) and the Administrator between 11:am-11:30am. LPA also conducted records review at 11:15am

Allegation: Resident fell sustaining injury due to staff neglect
It was alleged that on 05/07/23, R1 fell due to the carpet in the hallway being ripped. To investigate this allegation, LPA conducted an interview with the Administrator and Business Office Director (BOD) and was informed that the entire facility carpet was being replaced with a new one and during the Resident Council Meeting on February 8th, 2023, the facility notified all residents to be more careful when going into their rooms. LPA was also informed that before the project started, the company that was hired to replace the carpet, had to identify what was underneath the carpet and in order to do so, they had to out the carpet (wall-to-wall). However, BOD confirmed that no duct tape nor a "CAUTION" sign was placed. LPA was informed that duct tape was put in two (2) days after R1's fall incident and the "CAUTION" sign was placed by R1. Although, interviews with thirteen (13) out of fourteen (14) residents confirmed that they were aware of the facility replacing carpet and were reminded by the facility staff to be more careful, the facility did not place safety cones or caution sings until after a fall incident occurred with R1. Based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated.


Allegation: Facility carpet is in disrepair
To investigate this allegation, LPA conducted an interview with the Administrator, Business Office Director (BOD) and Maintenance man. Interviews revealed that on February 3rd, 2023 the facility carpet was approved to be replaced and the facility hired licensed vendors to complete the job (starting on February 14th, 2023). During todays visit Administrator stated that the carpet is being replaced due to being very old. Based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated

Deficiencies issued per Title 22.

Exit interview conducted, appeal rights explained and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 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)
Page: 2 of 3
Control Number 31-AS-20230509161340
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2023
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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As of todays visit POC is cleared
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Based on interviews and record reviews the licensee failed to ensure that the facility is in good repair due to the carpet needed to be replaced because of continues wear and tear, which poses a potential health and safety risk to the residents in care.
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Type B
06/28/2023
Section Cited
CCR
87468.1(a)(2)
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(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 is not met as evidenced by:
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Administrator agreed to provide a written agreement that outlines any future renovation. Any Future Renovation, shall have warning signs or postings as soon as project starts. Copy of this agreement will be emailed to LPA
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Based on interviews and record reviews the licensee failed to ensure that the facility posted warning signs during the carpet replacement, which poses a potential health and safety risk to the residents in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3