191290642-6-21-2023-31-AS-NGID-CUTT27-20230818142014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 06/21/2023
Date Signed: 06/21/2023 02:16:55 PM

Unsubstantiated

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
06/02/2023 and conducted by Evaluator Melissa Ruiz

COMPLAINT CONTROL NUMBER: 31-AS-20230602142940

FACILITY NAME:	LEISURE VALE RETIREMENT HOTEL		FACILITY NUMBER:	191290642
ADMINISTRATOR:	CELIA GARCIA		FACILITY TYPE:	740
ADDRESS:	413 E. CYPRESS		TELEPHONE:	(323) 697-2248
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	199	CENSUS: 109	DATE:	06/21/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Celia Garcia - Administrator		TIME COMPLETED:	02:16 PM

ALLEGATION(S):

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Residents missed medications due to lack of staff.

INVESTIGATION FINDINGS:

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On 6/21/23, Licensing Program Analyst (LPA) arrived at the facility to conduct a subsequent complaint visit. Upon arrival, LPA was greeted by the Administrator, Celia Garcia. An entrance interview was conducted, and the purpose of the visit was explained.

Residents missed medications due to lack of staff.

It was alleged that on or around 5/30/23 at about 3:00 or 4:00 a.m., R1 missed their PRN medication due to no med-tech staff on shift. During today’s visit, LPA conducted interviews with R1, the Administrator, a med-tech #2 (S2), and another staff member (S3) from 10:30 a.m. – 12:45 a.m. Additionally, LPA conducted a record review and collected the following: LIC500, resident roster, R1’s medication list, R1’s Individual Resident Narcotic Record (PRN), Updated medication instructions form R1’s physician dated 4/13/23.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
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)

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Control Number 31-AS-20230602142940

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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Interviews conducted with the Administrator and three staff on 6/8/23 and today, revealed that for the NOC shift, there is a med tech on shift from 11:00 p.m. – 7:30 a.m. Additionally, interviews revealed that there are other staff who are training to give medications, if needed. The Administrator confirmed that on 5/30/23, a med tech called out for their 11:00 – 7:30 a.m. shift, however there was another staff (S1) at the facility who is trained to assist with medications. This was confirmed by an interview with S1 and S3. S3 also confirmed that on 5/30/23, the Administrator called them, and asked them to come in to assist due to the med-tech on shift calling out. S3 confirms that they came in between 4 - 4:30 a.m. and observed R1 in the entryway, but R1 did not ask or mention anything regarding their need for medication and R1 simply greeted S3. R1’s PRN record shows that R1 received their Clonazepam (PRN) on 5/30/23 at 5:47 a.m., 5/31/23 at 8:00 a.m. and 11:00 p.m.

Due to interviews and record review, there is insufficient evidence to support that the allegation, may or may not have occurred. Therefore, the allegation resident missed their medications due to lack of staff is deemed UNSUBSTANTIATED at this time. Report signed and delivered. Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
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)

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