191290642-8-11-2023-28-AS-MVAO-CUTSS9-20230818140732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/11/2023
Date Signed: 08/11/2023 05:29:50 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
01/28/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210128135224

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: 121	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Celia Garcia, administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident sustained Level 4 pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted a subsequent unannounced complaint investigation for the allegation listed above today. LPA met Administrator, Celia Garcia and explained the purpose of today's visit.

On 01/29/21, LPA Tao conducted the initial investigation visit via tele-conferencing with Administrator, Jesse Mota due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. LPA obtained staff roster and resident roster.

On 07/31/23, LPA conducted a subsequent unannounced complaint investigation at the facility. During the visit, LPA obtained a copy of staff roster, resident roster, Resident #1 (R1) facility files and related documents. LPA interviewed staff from staff #1 to staff #6 at the facility and interviewed staff#7 over the phone. LPA requested R1's home health documents and R1’s progress notes.

(-continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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-20210128135224

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: 08/11/2023

NARRATIVE

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On 08/01/23, LPA conducted another subsequent unannounced complaint investigation. During the visit, LPA obtained copies of staff and resident rosters, Resident #1 (R1) progress notes and related documents.
LPA interviewed residents from resident#2 (R2) to resident#14 (R14) and attempted to interview resident#1 (R1), resident#15 (R15) and resident#16 (R16). LPA requested R1's home health documents regarding to resident's pressure injury. LPA was unsuccessful in attempts to interview R#1, who was deceased.

On 8/11/23, LPA obtained a copy of staff roster, resident roster, additional related documents from R1’s file. LPA interviewed staff #8, administrator.

Investigation consisted of the following: interviews of staff from staff#1 (S1) to staff#8 (S8); interviews of residents from resident#2 (R2) through resident#14 (R14); reviews of resident#1’s record reviews; and tour of the physical plant.

In regard of the allegation, “resident sustained Level 4 pressure injury while in care,” it was alleged that resident#1 (R1) sustained a level 4 pressure injury and an unstageable pressure injury due to neglect. The investigation revealed the following: Per resident interviews from R2 to R14, all thirteen (13) residents could not corroborate the allegation. LPA attempted but was unable to interview R#1 who was deceased. Resident interviews revealed staff would assist residents to turn/reposition in beds and wheelchairs every two hours or throughout the day. Per staff interviews from staff#1 (S1) to staff#8 (S8), all staff denied R1’s pressure injuries were due to neglect or lack of care. Interviews with staff revealed that staff would follow home health instructions to assist or prompt R1 to reposition/turn every two hours. Staff would elevate R1's feet by putting a pillow between legs while R1 was in bed. Per record reviews, R1 received home health care since the 2nd day admitted to the facility and R1 was able to get in /out of the wheelchair unassisted. During a site visit on 08/01/2023, LPA observed staff would assist residents who required assistance with repositioning in bed and wheelchairs as needed. Therefore, there is not preponderance evidence to prove R1 sustained pressure injuries were due to neglect.

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.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.
An exit interview was conducted with Administrator, Celia Garcia. A hard copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

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