<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610032
Report Date:
07/11/2022
Date Signed:
07/11/2022 01:24:00 PM
Document Has Been Signed on
07/11/2022 01:24 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 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:
07/11/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:30 PM
MET WITH:
Jessica Pelaya
TIME COMPLETED:
01:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Wendell Smith conducted a case management visit in conjunction with a complaint visit. LPA met with the administrator and explained the reason for this visit.
Incident report was received detailing that resident #1 (R1) slammed the door on resident #2 (R2) hand resulting in an injury for R2. LPA conducted an interview with the administrator and R1 regarding this incident. LPA also obtained copies of the incident report and a witness statement from a resident who witnessed the alleged altercation. Law enforcement did come out regarding the altercation and LPA obtained the report number. LPA will forward the information to the case carrying LPA for follow up action.
Exit interview conducted.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
07/11/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/11/2022
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
1