197610032-7-21-2021-31-AS-MSPH-C5623W-20210721170257

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 07/21/2021
Date Signed: 07/21/2021 05:06:16 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 FACILITY		FACILITY NUMBER:	197610032
ADMINISTRATOR:	LABELLA, MARK J		FACILITY TYPE:	740
ADDRESS:	44523 15TH STREET WEST		TELEPHONE:	(661) 941-4578
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	157	CENSUS: 110	DATE:	07/21/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Tannya Quezada		TIME COMPLETED:	04:40 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	LPA conducted a case management-incident report visit and arrived at 2:35 pm. LPA was greeted by Administrator Designee, Tannya Quezada. LPA observed staff wearing a mask upon entry to the facility. LPA explained the purpose of the visit was to speak to Administrator Designee regarding three incident reports. LPA Spaeth stated would like to review residents' files and speak to staff members regarding incidents. LPA reviewed records from 2:45 pm until 3:25 pm. Two reports stated two residents were AWOL from the facility. LPA Spaeth requested Administrator Designee to explain procedure staff follow when resident is AWOL. Administrator Designee stated Caregivers complete the following room checks each evening: 7:00 pm, 9:00 pm and 12:00 midnight. All residents' rooms are thoroughly checked. A 3:00 am check takes place where residents who need adult diapers to be changed. Administrator Designee also stated residents' rooms are also checked at 3:00 am who have previously eloped from the facility. Also, the night shift staff check every room at 7:00 am. If a resident is missing during room checks, caregivers will search the entire facility. If resident cannot be found, staff will called Administrator Designee, call 911 and search in cars the neighborhood. Administrator Designee confirmed residents menteind in the incident reports were found. Administrator Designee has implemented additional checks to be completed throughout the day for the residents who previously eloped from the facility.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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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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
	VISIT DATE: 07/21/2021

NARRATIVE

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LPA Spaeth spoke to Administrator Designee regarding incident report stating on July 18, 2021, a resident was found by a caregiver with a metal hanger around resident's neck. Caregiver immediately tried to remove hanger but could not remove the item. Caregiver called another staff member who was able to remove the hanger.

Administrator Designee confirmed resident was conscious but Administrator Designee was called and caregiver immediately called 911. Administrator Designee confirmed that resident is being treated in a hospital. Administrator Designee stated spoke to resident's clinician who stated when resident returns to facility, Clinician will be checking on the resident two times per week. Administrator Designee stated plan is in place for staff and Administrator Designee to frequently check on the resident once the resident is returned to facility. Administrator Designee also stated resident will be moved to a different room closer to the Administrator offices so all staff members can frequently check on resident.

LPA concluded visit at 4:30 pm. Exit interview conducted, appeal rights discussed, and LPA confirmed a copy of the report will be emailed to Administrator Designee.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC809 (FAS) - (06/04)

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