197610032-6-8-2022-31-AS-CHAS-CGCU7B-20220715151941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 06/08/2022
Date Signed: 06/08/2022 05:01:25 PM

Unsubstantiated

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
06/07/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220607141653

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:	06/08/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff members are over-medicating resident with over the counter medication

Medical Technician is disrespectful to resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Spaeth conducted an unannounced visit to the facility and was greeted by Administrator Jessica Pelaya. LPA stated the purpose of the visit was to conduct a complaint which states staff members are over-medicating resident with over the counter medication and staff member is disrespectful to resident. Upon arriving LPA's temperature was recorded and COVID questions answered at the sign in station.

LPA conducted a tour of the facility from 1:10 pm until 1:35 pm. LPA did not observe any health or safety issues at this time. LPA interviewed resident from 1:35 pm until 1: 55 pm. LPA reviewed resident medication records from 2:00 pm until 2:10 pm and requested copies. LPA also reviewed resident records from 2:15 pm until 2:35 pm. and requested copies. LPA interviewed staff member from 2:10 pm until 2:42 pm.

In regard to staff members are over-medicating resident with over the counter medication, LPA interviewed the Resident (R1) who stated R1 is receiving two doses of a specific medication each day. LPA observed the medication label for the medication in question and saw the label states the medication dose is one dose per

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: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 31-AS-20220607141653

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: 06/08/2022

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
26
27
28
29
30
31
32

day. LPA observed the medication administration and centrally stored medication sheet which indicates the resident refused the medication for the last four days. The medical technician stated that when residents refuse the medication, the medication is properly disposed and not left with the resident. The medical technician
stated follow the medication distribution policies of the facility and confirmed give accurate doses of the medication. Therefore, this allegation is unsubstantiated.

LPA interviewed medical technician mentioned in the complaint and asked if had been disrespectful to resident. Medical Technician stated no. LPA interviewed R1 and asked if medical technician had been disrespectful to resident and resident stated medical technician had not been disrespectful to resident. LPA asked if medical technician has ever made derogatory remarks to R1 and R1 stated no. Therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2