191290642-7-31-2023-28-AS-FFIS-CUE2TJ-20230804174048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 07/31/2023
Date Signed: 07/31/2023 05:15:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/28/2022 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221128095338

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: 120	DATE:	07/31/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Assistant Administrator - Nilda Mercado		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident was sexually abused while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced subsequent complaint investigation to deliver findings regarding the above stated allegation. LPA met with Assistant Administrator - Nilda Mercado

On 11/29/22, LPA Calderon conducted an initial health and safety check visit which included: LPA obtained copies of Staff & Resident Rosters. LPA Calderon toured physical plant with Celia Garcia, toured common areas: dining room, TV/ Recreational room and living room. LPA also toured rooms of resident #1 &2 (R1 & R2) and observed residents in rooms. LPA collected the following documents: R1's Physician Reports, Individual Service Plan, Resident's Progress Notes and Unusual Incident Reports. LPA Calderon interviewed R1. LPA did not observe any immediate health and safety concerns.LPA interviewed Resident #1 (R1).

On 7/28/2023 LPA interviewed current Administrator Celia Garcia (Staff #1 -S1) via telephonically.
Continuation 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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-20221128095338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 07/31/2023

NARRATIVE

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On today's visit 7/31/22, visit consisted of the following: LPA collected copies of staff and resident roster. LPA interviewed Residents #3-#11 (R3-R11), and LPA interviewed staff Assistant Administrator Nilda Mercado (Staff #2- S2) and interviewed Staff #3-Staff #7, (S3-S7). LPA attempted to interview Staff #8 and #9 via telephonically. LPA collected staff documentation on :Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders, Harassment Policy Acknowledgment, Elderly Dependent Abuse Statement, Certificate of Elder Abuse and Certificate of Preventing, Recognizing, and Reporting Abuse.

Regarding Allegation: Resident was sexually abused while in care. Based on investigation the following was revealed. Interviews with S1-S7 revealed all staff denied the above allegation stating resident(s) are not sexually abused while in care and have not sexually abused a resident in care. Interviews with residents, R3-R11 revealed residents are aware what sexual abuse is and have not been sexually abused in care or know of residents who have been sexually abused while in care. LPA Calderon reviewed staff documentation's on sexual abuse Acknowledgment and Training. All staff have documentation's signed on Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders. However, the investigation did not reveal residents or R1 was sexually abused while in care, there is no evidence to support the above allegation. Therefore, the allegation is deemed unsubstantiated per Title 22 Regulations, Division 6, Chapter 8.

Based on LPA's observations, record review and interviews, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC9099 (FAS) - (06/04)

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