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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 02/19/2021
Date Signed: 02/19/2021 04:56:33 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) 941-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:157CENSUS: 89DATE:
02/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Tannya QuezadaTIME COMPLETED:
04:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spaeth initiated a case management -incident visit with Tannya Quezada, Administrator Designee and explained the purpose of the visit was to investigate an incident that occurred at the facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management visit was conducted as a FaceTime visit with Tannya Quezada, the Administrator Designee for the Leisure Garden Senior Assisted Living Facility.

LPA Spaeth confirmed receipt of an incident report dated February 14, 2021 which stated a resident (R1) had grabbed another resident's hair (R2) and R1 pulled R2 out into the hallway of the facility. Sheriff was called and R1 was taken away by Sheriff from the facility. On February 17, 2021, LPA Spaeth received a second incident report stating R1 returned to the facility and was at the front entrance. A staff member (S1) went to the front entrance and R1 began cursing and kicking the front door of the facility. S1 stated R1 moved to the side door, which is the staff entrance and R1 broke the glass to the side door. S1 told R1 that R1 could not enter the facility due to R1's behavior. The Sheriff was called and R1 was taken to jail.

On February 19, 2021, LPA Spaeth spoke to Administrator Designee at 11:00 am regarding incident reports. Administrator Designee stated a eviction letter was issued to R1 dated February 7, 2021. Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit. Exit Interview conducted and copy of report emailed to licensee.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2021
Section Cited

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87224(a) A written report of any eviction shall be sent to the licensing agency within five (5) days. This reqiuirement was not met as evidenced by:
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Facility issued a thirty-day notice of Eviction to the Resident dated February 7, 2021. Facility failed to forward the eviction notice to LPA by February 12, 2021.
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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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2021
LIC809 (FAS) - (06/04)
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