197610032-4-6-2022-31-AS-CHAS-CDGTZH-20220414151022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 04/06/2022
Date Signed: 04/06/2022 05:34:36 PM

Substantiated

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
04/01/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220401151549

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: 107	DATE:	04/06/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident wandered away from the facility

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unannounced visit and was greeted by the Administrator, Jessica Pelaya. LPA's temperature was recorded and LPA answered the COVID questions upon entering the reception area of the facility. LPA stated the purpose of the visit was to investigate an allegation, resident wandered away from the facility.

LPA interviewed the Administrator and a caregiver from 11:45 am until 12:30 pm. LPA reviewed resident's file from 12;30 pm until 12:40 pm. LPA interviewed Resident (R1) at 1:00 pm. LPA conducted a brief physical plant tour from 1:00 pm until 1:20 pm to ensure there were no immediate health and safety issues.

Administrator was interviewed by LPA and Administrator stated a resident had set off the fire alarm the morning of April 1, 2022 at approximately 5:00 am. Administrator also stated there were two caregivers working at that time. The exit door near Room 137 was not completely shut. The caregiver who observed the door was not

Substantiated

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: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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-20220401151549

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: 04/06/2022

NARRATIVE

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secure did not report the incident to the Administrator. Administrator stated R1 left the facility between 5:00 am and 7:00 am. Administrator stated had reminded Caregiver (S1) must make sure the exit doors are secure and S1 must also immediately report all incidents to the Administrator.

LPA also interviewed the second caregiver (S2) who was working the morning of April 1, 2022. S2 stated had seen R1 at 5:00 am within the facility. S2 stated R2 set off the fire alarm at approximately 5:00 am. S2 did not witness R1 leaving the building but stated probably exited the building between 5:00 am and 7:00 am.

Administrator confirmed the R1 returned to the building at 11:00 am.

LPA reviewed resident's file and observed the Physician's Report for R1 states the resident is not able to leave the facility unassisted.

Based upon LPA's interview of the Administrator and the Caregiver and the resident's Physician Report, the allegation is substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220401151549

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/06/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a) In addition to the rights listed in Section 87468.1, ... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, ...This requierment was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has already counseled the caregiver in question. Administrator has reviewed the facility procedures with the Caregiver and a documented verbal warning was issued to the caregiver.
	8 9 10 11 12 13 14	Based upon LPA's interviews of the Administrator and Caregiver, Caregivers were not aware the resident had left the building without an escort, which is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC9099 (FAS) - (06/04)

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