191290642-7-31-2023-28-AS-FFIS-CUE2C7-20230804171617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 07/31/2023
Date Signed: 07/31/2023 01:07:51 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
10/25/2022 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221025110023

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:	09:20 AM
MET WITH:	Aissistant Administrator- Nilda Mercado		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident was left in a soiled diaper for a long period of time.
Facility ignored resident.
Resident's hygiene needs are not being met.

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 allegations. LPA met with Assistant Administrator Nelda Mercado.

On initial visit 11/1/22, Licensing Program Analyst (LPA) Ashley Calderon and staff Nilda Mercado toured the hallways of residents rooms, went in Resident #1 (R1) bedroom and toured the living room area. LPA Calderon collected resident and staff roster. LPA Calderon collected R1's physician report and face sheet, Home Health Care documentation, Hospital discharge, police report number and Unusual Incident Report related to the above allegations. LPA interviewed staff #1 (S1) and staff #2 (S2). LPA interview residents #2 (R2),#3 (R3) , #6 (R6), and #7 (R7). LPA attempted to interview R1, Resident #4 (R4), #5 (R5) and #8 (R8). LPA interviewed Staff #2-#4 and staff #6 (S2-S4 & S6) were interviewed via telephonically on 11/7/22 and Staff #5 (S5) interviewed via telephone on 11/9/22. (Contuniation on 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-20221025110023

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 7/31/23 LPA Calderon visit consisted of: LPA collected resident and staff roster and attempt to interview R1. LPA observed linen closet and hygiene supplies in Room 1 (Conference Room).

Regarding Allegation: Resident was left in a soiled diaper for a long period of time. During LPA’s visit the following was revealed: During interviews with Staff, S1-S6 all denied the above allegation that residents are attended to, get incontinent care and are not left soiled for a long period of time. All staff stated for incontinent residents’ staff do rounds every 2 hours or as needed to assist residents with toileting needs or other activity of daily living needs a resident may have. Interviews with residents: R2, R3, R6 and R7 are unaware if other residents are left in soil for a long period of time. R2, R3 and R6 stated they are checked by staff, staff assist with changing adult briefs and are not in soiled diapers for a long period of time. LPA attempt to interview R1 on 11/1/22 and 7/31/23 and was not successful. R7 interview revealed they do not get incontinent care and could not relate to above allegation. LPA Calderon reviewed documentation for R1 who is receiving Home Health Services. Unusual Incident Report for incident occurring on 10/21/22 for R1 states R1 was not allowing assistance from facility and was hospitalized for not being compliant with receiving care. The investigation did not reveal resident(s) being left in soiled diapers for a long period of time. Therefore, the allegation is deemed unsubstantiated per Title 22 Regulations, Division 6 Chapter 8.

Regarding Allegation: Facility ignored resident. During LPA’s visit the following was revealed: During interviews with Staff, S1-S6 all denied ignoring resident(s) that staff have not personally ignored any residents including R1 and have not witnessed resident(s) being ignored. S3,S4 and S6 stated staff preform their duties and check in on resident(s). Interviews with residents, R2,R3,R6 and R7 denied the above allegation stating they are not ignored by facility and staff interact with residents to assist with each residents needs. LPA attempt to interview R1 on 11/1/22 and 7/31/23 and was not successful. On 11/1/22 LPA observed R1’s door having a sign stating No Housekeeping. LPA reviewed UIR documentation for R1 stating R1 was transferred to the hospital for assistance when R1 did not allow facility to assist with care. The investigation did not reveal that facility ignore resident(s). Therefore, the allegation is deemed unsubstantiated per Title 22 Regulations, Division 6 Chapter 8.

Regarding Allegation: Resident's hygiene needs are not being met. During LPA’s visit the following was revealed: Interviews with staff, S1-S6 denied above allegation and stated residents hygiene needs are being met, staff do rounds to residents rooms every 2 hours, staff assist with incontinent care, hygiene needs like showering and dressing residents. S1 stated R1 doesn’t allow caregivers to go inside R1’s room and assist R1, it is only when R1 wants to and will ask for assistance. S2 stated R1 wants specific caregivers to assist R1’s needs and refuses care from certain staff and R1 has a sign on room door stating not allowing housekeepers to go in their room. LPA observed R1’s door having a sign stating:No Housekeeping. LPA Calderon reviewed documentation for R1, doctor ordered Home Health Services. Unusual Incident Report for incident occurring on 10/21/22 for R1 states R1 was not allowing assistance from facility and was hospitalized for not being compliant with receiving care. LPA observed sufficient linen and hygiene supplies. The investigation did not reveal resident's hygienes needs are not being met.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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