191290642-8-29-2023-31-AS-NMAN-CWNV5R-20231016160819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290642
Report Date: 08/29/2023
Date Signed: 08/29/2023 04:26:56 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
06/12/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230612105528

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:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Nilda Mercado		TIME COMPLETED:	04:28 PM

ALLEGATION(S):

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Staff did not provide medical attention to resident in a timely manner.
Staff do not ensure resident's medications are filled.
Staff do not administer medications to resident as prescribed.
Staff are not putting appropriate measures into place for resident who is a fall risk.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with the Assistant Administrator, Nilda Mercado, and explained the reason for the visit.

--- Staff did not provide medical attention to resident in a timely manner.

It was alleged that staff did not assist Resident #1 (R1) when R1 was choking on a small piece of rib bone. To investigate the allegation, on 06/20/2023 LPA interviewed three (03) staff from 11:30 AM – 01:00 PM and interviewed six (06) residents between 1:30 PM to 3:30 PM. On 08/29/2023 at around 12:00 PM, LPA interviewed three (03) additional residents.

(CONT. LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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-20230612105528

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: 08/29/2023

NARRATIVE

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During interviews with staff, Staff #1 (S1) stated Staff #4 (S4) reported to them that R1 was breathing, talking, did not look distress, but R1 was requesting to go to the emergency room. S4 had no problem calling for an ambulance, but before S4 could, R1’s friend had already called. Staff #2 (S2) and Staff #3 (S3) are unaware of the situation and Staff #4 (S4) was not available for interviews. During interviews with residents, R1 stated staff refused to call 911 and that R1 ended up calling 911 themselves. All other residents stated that they have never experienced delays in emergency medical attention.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff do not ensure resident's medications are filled.

It was alleged that R1 has not received their medication refill after requests. To investigate the allegation, on 06/20/2023 LPA interviewed three (03) staff from 11:30 AM – 01:00 PM and interviewed six (06) residents between 1:30 PM to 3:30 PM. On 08/29/2023 at around 12:00 PM, LPA interviewed three (03) additional residents. During interviews with staff, S1 is unaware of any medication or prescription refill issues. S2 stated R1 is well aware of the situation, and facility has been calling for the past three or so weeks. S2 added that R1 has a previous unpaid balance and pharmacy stated they will not deliver the medication unless the balance is paid. During interviews with residents, R1 stated it is their own responsibility to contact the physician to refill medications but that at times they need assistance. R1 stated they finally got the medication, but it was defective and is currently waiting for a replacement. All other residents stated they do not have issues with getting medication refilled.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff do not administer medications to resident as prescribed.

It was alleged that R1 was being given more medication than prescribed.

(CONT. on LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230612105528

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: 08/29/2023

NARRATIVE

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To investigate the allegation, on 06/20/2023 LPA interviewed three (03) staff from 11:30 AM – 01:00 PM and interviewed six (06) residents between 1:30 PM to 3:30 PM. On 08/29/2023 at 10:30 AM, LPA requested additional records and at around 12:00 PM, interviewed three (03) additional residents. During interviews with staff, S1 stated that R1 refused to take medication because the color of the pill changed and S3 stated that all medications are administered as prescribed. During interviews with residents, R1 stated staff are giving more than the prescribed medication. All other residents stated that medications are given as prescribed. A review of R1’s Medication Administration Records revealed that resident was given one of the two medications in question as prescribed and the other was given as per resident’s needs or request.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff are not putting appropriate measures into place for resident who is a fall risk.

It was alleged that R1 was placed on the second floor even though staff knew R1 was a fall risk. To investigate the allegation, on 06/20/2023 LPA interviewed three (03) staff from 11:30 AM – 01:00 PM and interviewed six (06) residents between 1:30 PM to 3:30 PM. On 08/29/2023 at 10:30 AM, LPA requested additional records and at around 12:00 PM, interviewed three (03) additional residents. During interviews with staff, S1 stated that according to doctor’s report, R1 is not a fall risk and that R1 mentioned once that they wanted to move to the first floor but assumed that R1 wanted to be close to their friend. S1 told R1 that when a room is available, R1 will be moved. All other staff were not aware of fall risk. During interviews with residents, R1 stated due to health issues they are a fall risk, and the physician is aware. A review of R1’s Physician’s Report revealed that R1 is not a fall risk, ambulatory and does not need assistance with activities of daily living. A review of the facility’s Incident Reports revealed that there were no fall incidents reported for R1.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.
Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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