191290642-4-8-2021-28-AS-MVAO-BZZUXK-20210412155827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 03/29/2021
Date Signed: 04/08/2021 04:38:26 PM

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
01/29/2020 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20200129125137

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	POLITA BARNES		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(818) 244-2323
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 71	DATE:	03/29/2021
		UNANNOUNCED	TIME BEGAN:	02:47 PM
MET WITH:	Assistant Administrator, Celia Garcia		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint tele-visit investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with Assistant Administrator, Celia Garcia.

The investigation consisted of the following: On 2/05/2020, LPA Almaraz and Licensing Program Manager (LPM) Christine Yee interviewed Assistant Administrators, Jesse Mota and Nilda Mercado, Staff #1-4 and Residents #1-3. Copies of staff and resident rosters, incontinent residents list, and Residents #1-3 files were obtained and reviewed. During the visit it was determined further investigation was needed. On 11/6/2020, LPA Almaraz interviewed residents #4-6 and attempted to interviewed residents #7-11 but was unsuccessful due to some residents being non-verbal and some refusing to interviewed.
(Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

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-20200129125137

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: 03/29/2021

NARRATIVE

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The investigation revealed the following: During interviews conducted with staff and residents, it was revealed a resident who has a history of Diaper Dermatitis had redness and inflammation in the groin and buttocks area. The resident was sent to the hospital on 1/28/2020 to be treated. LPA interviewed several incontinent residents who stated they are changed frequently. The resident who sustained the redness and inflammation in the groin and buttocks area stated they change them often and they have a call system in place to use when they need assistance. Documents reviewed revealed the resident has been having this diaper rash come and go since 2016. All staff interviews conducted revealed incontinent residents are checked on every 2-3 hours or as needed.

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 is Unsubstantiated.

A telephonic exit interview was conducted with Garcia and a copy was provided via email for signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

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