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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 11/03/2020
Date Signed: 11/03/2020 03:04:08 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 FACILITYFACILITY NUMBER:
197610032
ADMINISTRATOR:LABELLA, MARK JFACILITY TYPE:
740
ADDRESS:44523 15TH STREET WESTTELEPHONE:
(661) 974-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:157CENSUS: DATE:
11/03/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ted BonzonTIME COMPLETED:
10:30 AM
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On 11/03/20 at 9:30am, Licensing Program Analysts (LPAs) Naira Margaryan and Melissa Spaeth conducted a virtual pre-licensing inspection, to verify the corrections previously discussed with the applicant.
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 was completed telephonically via face-time.
During this inspection LPAs inspected the physical plant, including the bedrooms, bathrooms, common areas, administrative offices and etc.
Upon inspection of physical plant, LPAs noted that all corrections previously noted during the Licensing visit conducted on 08/21/20.
LPA reviewed all the COVID-19 signs posted in the facility and discussed the COVID-19 emergency procedures and recent requirements that the facilities should follow based on the information provided to the Licensees via Providers Information Network (PIN). (PIN-20-23; PIN-20-28).
The component 3 was completed virtually on 10/30/2020.
Based on the inspection, interviews and review of the documents, the physical plant is meeting Licensing requirements.

Exit interview is conducted telephonically.
A copy of this report was sent to the applicant for review and signature.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira MargaryanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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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