191290642-4-1-2021-28-AS-MVAO-C22M5E-20210413091814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 03/30/2021
Date Signed: 04/01/2021 08:32:18 AM

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
09/16/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20200916170156

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:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Celia Garcia - Assistant Administrator Jesse Mota - Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Celia Garcia, the facility assistant administrator.

The investigation consisted of the following: On 9/22/20 LPAs Flores and Wilkerson conducted telephone interviews with theJesse Mota assistant administrator, and a video call which consisted of a review of food supply, and physical plant; common areas, elevator, rooms #214, 210, 212, 211, 312, 303, 307, and 311. The LPA also requested copies of physician's report, needs and service plan, medication sheets, admissions agreement, and repair invoice to be emailed to the LPA by 9/23/20. On 3/30/21 LPA Flores met with Celia Garcia assistant administrator and interviewed Residents #1,#2,#3,#4,#5,#6,#7 (R1,R2,R3,R4,R5,R6,R7) and staff #1,#2,#3,#4,#5,#6 via video call and telephone.
(Continued on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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-20200916170156

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: 03/30/2021

NARRATIVE

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The investigation revealed the following: Regarding allegation; Facility is in disrepair. It's alleged elevator had been out for three days. Interviews with 4 out of 7 residents stated elevator was out for more than one day and used the stairs to get up and down the building. 2 out of 7 residents stated the elevator was out between a couple of hours to a day and 1 out of 7 residents stated not to know if elevator was out. 5 out of 7 staff stated not to be aware that the elevator was out. 2 out of 7 staff stated elevator was out either for a couple of hours or overnight. Review of documents showed elevator had an invoice from an elevator service company in which shows the elevator was repair on 8/27/20.

Based on LPA's interviews conducted and documents reviewed the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with administrator Jesse Mota, and a copy of the report was email was email for signature, along with Appeal Rights.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20200916170156

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/13/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation; (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility provided a copy of repair invoice on 10/14/20. Therefore the plan of correction has been clear.
	8 9 10 11 12 13 14	Based on interviews and documents reviewed the facility's administrator stated the elevator was not working and repairs were necessary which poses a potential Health, Safety, or Personal RIghts risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

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