197610032-3-10-2022-31-AS-CHAS-CCYS9G-20220329134040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 03/10/2022
Date Signed: 03/10/2022 05:44:05 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
02/22/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220222114752

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: 108	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:			TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Caregivers did not provide proper care to resident

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unannounced visit and was greeted by Administrator, Jessica Pelaya and Licensee Ted Nelson. LPA's temperature was recorded and LPA answered COVID questions. LPA explained the purpose of the visit was to provide LPA's findings regarding the allegation, Caregivers did not provide proper care to resident.

LPA Spaeth conducted a brief physical plant tour from 2:25 until 2:45 to ensure no immediate health and safety issues were noted. LPA interviewed three caregivers from 2:50 pm until 3:25 pm.

R1 had stated resident's bed has not been changed. During LPA's interview of the resident (R1) on 2/23/2022, R1 had stated did not allow caregivers to change bed so that the LPA could see feces in the bed. Also, Caregiver D. Kent had stated to LPA today that S1 went to change R1's soiled sheets but R1 would not allow S1 to change the bedding. Also, LPA interviewed two additional caregivers who stated soiled bedding is always changed by caregivers. Therefore this statement is unsubstantiated.

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: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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-20220222114752

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: 03/10/2022

NARRATIVE

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R1 had stated to LPA Spaeth on 2/23/2022 that R1 did not receive medication on 2/21/2022, 2/22/2022, and 2/23/2022. LPA interviewed med tech A. Flores on 2/23/2022 at 2:00 pm who stated R1 has been prescribed medication as a PRN. S1 stated R1 had requested medication on 2/21/2022, 2/22/2022 and 2/23/2022. LPA spoke to Med Tech Erika Valdez (S4) today at 4:30 pm who provided the medication administration & Centrally Stored Medication Record which states R1 did receive the morphine medication. Therefore, this allegation is unsubstantiated.

R1 had stated that medication could not be refilled by staff members. However, LPA received a copy of the prescription order from the doctor which states the medication had been refilled. Therefore, this allegation is unsubstantiated.

Exit interview as conducted, appeal rights discussed, and a copy of the signed report was given to the Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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