197610032-8-25-2020-31-AS-NMAN-BSTUM6-20200825154149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 08/21/2020
Date Signed: 08/25/2020 03:42:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY		FACILITY NUMBER:	197610032
ADMINISTRATOR:	LABELLA, MARK J		FACILITY TYPE:	740
ADDRESS:	44523 15TH STREET WEST		TELEPHONE:	(661) 974-4578
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	157	CENSUS: 97	DATE:	08/21/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Ted Bonzon		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/21/20 at 8:30pm Licensing Program Analysts (LPAs) Naira Margaryan and Rosaura Valenzuela conducted pre-licensing inspection. The application for "Leisure Garden Senior Assisted Living" is for change of ownership. The facility currently is operating as an "Antelope Valley Retirement Villa". Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s inspection report was completed at later time, after the inspection. Upon entry to the facility the staff checked LPAs temperature, LPAs completed written questioner and the staff sprayed LPAs shoes with the alcohol based sanitizer. Upon arrival LPAs met the applicant Ted Bonzon and the representative of the currently open facility "Antelope Valley Retirement" Naira Kostandyan. The purpose of this visit was discussed. With the assistance of the applicant and other staff, at 9:15am, LPAs inspected facility for Fire Safety, Personal Accommodations and Services, Food Service, and Medication Procedures. LPAs observed all required signs and postings as per Emergency Requirements due to corona virus Disease. Fire clearance has approved all rooms for non-ambulatory and rooms 103, 105, 107 and 109 for bedridden. Facility also has automatic fire doors. The applicant indicated that they may request additional bedridden fire clearance before final licensure. The Administrative Offices, Large conference room, dining room, staff launch, two Activity/TV rooms and medication room were located on the first floor. The facility had two sets of washer and dryer for the staff and clients use on the first and second floor

SUPERVISOR'S NAME: Maryjo Schnitzer	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 08/21/2020

NARRATIVE

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The laundry room on the first floor was observed and seemed new and functional. There were cabinets with locks adjacent to the laundry machines for chemicals to be stored.
The hallways were clean and had adequate lighting. LPAs observed working smog and carbon monoxide detectors in the hallways.
Fire extinguishers were observed throughout whole facility including kitchen and hallways and were fully charged. (Last inspection was done on 10/21/2019).

The common areas on the second floor was temporarily closed due to COVID-!9.
One of the activity rooms on the first floor was open and LPAs observed residents sitting in the room, wearing masks and keeping social distancing.

The facility Kitchen was inspected and meets food service requirements. LPAs observed commercial Kitchen equipment in working condition. There were few small areas of the commercial stove and few other equipment requiring cleaning and the staff cleaned the areas during this visit.
The dining room was observed and the tables and the chairs were set up to meet the COVID-19 emergency requirements.
Staff indicated that most residents are still eating in their rooms. However, the residents requiring feeding assistance and/or supervision during meal time, were eating in the dining room under staff supervision.

The bedrooms on the first and second floors were inspected. All rooms were designed for double occupancy. Most rooms had no chairs, broken nigh stand and other pieces of furniture.
There were rooms that had new beds, new mattresses and new night stands. However, there were rooms that had old mattresses covered with stains. LPAs observed that the mattress covers and sheets were missing, pillows were flat and must be replaced. Most rooms had No adequate lighting. There were no adequate lighting in the rooms,
Room 218 - LPAs observed dead bed bug, Broken night stand and one chair. Room 263-no mattress cover and no sheets. Room 243- torn carpet. Room -233 no night stand. Room - 203 broken mirror no chairs. Other bedrooms also had old mattresses covered with dark stains.

SUPERVISOR'S NAME: Maryjo Schnitzer	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 08/21/2020

NARRATIVE

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LPAs observe grab bars properly installed in every bathroom. The emergency signal system is not working throughout the facility. The applicant indicated that they are planning either to use pendants for all facility clients or voice activated "Amazon Eco" wireless devices that will be connected to the front desk. The system will be located in each residents bedroom.
There is no delayed egress system, no swimming pool or spa on premises. Facility has a patio area located outside and a courtyard located on the ground level in the middle of the facility The two activity rooms are adjacent to the court yard. Both activity rooms have direct exits to the courtyard through the large patio doors. The second activity room on the first floor was full of furniture and currently is being used as a storage. One of residents rooms was full of assisting medical equipment and is also used as a storage. LPAs advised the applicant that facility must have designated storage room and move the furniture and other medical equipment to the designated storage space. Applicant also was advised that if they are using the activity room and residents bedroom as a storage space, than they must identify the space on the facility sketch and reduce the total capacity of the facility.
Applicant informed the LPAs that the activity room and the bedroom will be used for residents and the items stored there will be removed.
LPAs also observed the common/activity room on the second floor which was temporarily closed. .
There were Storage rooms, laundry room, activity rooms on the second floor as well. There are complete First-aid kits on each floor.
During inspection LPAs observed the walls in the hallways, in the dining room and in the bedrooms that need patching and painting.
LPAs also inspected the roof access which is accessible via a ladder from a storage room from the 2nd floor of which will be kept locked. The stairwells do not have access to the roof.
All noted deficiencies were discussed with the applicant and they were advised that prior to licensure of the facility, all noted deficiencies must be cleared and Licensing office must be notified about corrections. Measurable and verifiable proof of corrections in the form of pictures and written documentation must be submitted to the LPAs via mail or e-mail.
Exit interview was conducted and the applicant was advised that due to the situation surrounding the Corona virus Disease 2019, report of pre-licensing inspection will be created at later time and a copy of the report will be e-mailed to the applicant for review and manual signature.

SUPERVISOR'S NAME: Maryjo Schnitzer	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

LIC809 (FAS) - (06/04)

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