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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 09/15/2022
Date Signed: 09/26/2022 05:32:16 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
07/08/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210708103731
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: DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jessica PelayaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Facility having resident sign up for services they don't need
INVESTIGATION FINDINGS:
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5
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9
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13
LPA Spaeth conducted an unannounced visit and was greeted by Administrator. LPA stated the purpose of the visit was to present LPA's findings for the allegation, facility having resident sign up for services they do not need.

LPA Spaeth reviewed resident's file at 10:45 am until 11:05 am. LPA requested a copy of the hospice provider, Tulip Hospice, Inc, Informed Consent form. LPA observed resident's signature which shows the resident did consent for the hospice services.

Therefore this allegation is unsubstantiated. Exit interview was conducted, appeal rights discussed, and a copy of the report was given to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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