197610032-12-8-2021-31-AS-CHAS-C9RT5V-20211216132612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 12/08/2021
Date Signed: 12/08/2021 04:53:03 PM

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
11/24/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20211124164314

FACILITY NAME:	LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY		FACILITY NUMBER:	197610032
ADMINISTRATOR:	JESSICA PELAYA		FACILITY TYPE:	740
ADDRESS:	44523 15TH STREET WEST		TELEPHONE:	(661) 941-4578
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	157	CENSUS: 116	DATE:	12/08/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident was prevented from getting medical treatment while in care

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unannounced visit to the facility. Upon arrival, LPA's temperature was taken and LPA signed in answering COVID questions. LPA was greeted by Administrator, Jessica Pelaya at 1:55 pm. LPA explained the purpose of the visit was to present LPA's findings regarding a complaint which stated resident was prevented from getting medical treatment while in care.

LPA Spaeth interviewed the resident mentioned in the complaint (R1) on November 29, 2021 who stated had left a note either November 27, 2021 or November 28, 2021 in the administrative office stating needed assistance the next morning at 5:00 am exiting the builidng for an Access ride to Long Beach. R1 could not remember who took the note but stated left a note. R1 stated missed the ride because the caregiver did not assist R1 and R1 could not remember the caregiver who refused to assist R1. LPA Spaeth interviewed both caregivers who were working the night shift (7:00 pm until 7:00 am) and both caregivers stated R1 did not leave a note requesting assistance the next morning.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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 31-AS-20211124164314

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 GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 12/08/2021

NARRATIVE

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Caregiver S. Phillips (S1) was interviewed 12/06/2021 at 7:30 pm who stated R1 did not notify staff that R1 needed assistance and did not leave a note. Caregiver D. Woodley (S2) was interviewed 12/06/2021 at 1:30 pm. S2 stated the morning of November 30, 2021 at 5:30 am, was completing morning rounds, walked by the front door and observed R1 was in wheelchair and was trying to exit the building. S2 went to assist R1 and R1 became angry and was cursing at S2. R1 stated had left a note regarding assistance out of the building for the Access ride but no staff member was present to assist R1. S2 stated apologized and assisted R1 out of the building by opening the door so that R1 could maneuver R1's wheelchair out of the building. S2 stated to R1 did not see a note and was not aware of R1's need for assistance.

LPA Spaeth also spoke to Administrator Designee, Jon Dipaling on 12/06/2021 at 3:00 pm who was at the facility on Friday, November 26, 2021 since Administrator, Jessica Pelaya was not working on that day. Administrator Designee stated R1 did not notify staff regarding need of assistance and there was no note provided to the staff by R1. LPA Spaeth also interviewed the weekend manager, Edgar Cruz on 12/06/2021 at 5:19 pm. Staff member Cruz stated was not notified by R1 needed assistance that weekend and did not leave a note for staff.

Based upon LPA's interview of four staff members, this complaint is unsubstantiated. Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC9099 (FAS) - (06/04)

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