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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 06/06/2022
Date Signed: 06/06/2022 06:27:40 PM


Document Has Been Signed on 06/06/2022 06:27 PM - It Cannot Be Edited

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:JESSICA PELAYAFACILITY TYPE:
740
ADDRESS:44523 15TH STREET WESTTELEPHONE:
(661) 941-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:157CENSUS: 113DATE:
06/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jon DipalingTIME COMPLETED:
05:00 PM
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LPA Spaeth conducted an unannounced visit and was greeted by Administrator, Jon Dipaling. Dipaling stated filling in for Administrator Jessica Pelaya as of today. LPA stated the purpose of the visit is to conduct a tour of the facility and request resident documentation. LPA received an incident report and a phone call from Dipaling regarding a resident incident that occurred at another location.

From 4:05 pm until 4:20 pm, LPA conducted a tour of the facility and determined there are no immediate health and safety issues at this time. From 4:30 pm until 4:45 pm, LPA reviewed resident records and requested copies of the records.

Further investigation is needed at this time. Exit interview conducted, appeal rights discussed, and a copy of the report was given to Dipaling..
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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