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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610032
Report Date:
11/17/2022
Date Signed:
11/18/2022 07:43:09 AM
Document Has Been Signed on
11/18/2022 07:43 AM
- 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:
115
DATE:
11/17/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
Jessica Pelaya
TIME COMPLETED:
02:30 PM
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LPA Spaeth conducted an unannounced visit and was greeted by Administrator. LPA stated the purpose of the visit was regarding an incident report received by CCL. The incident report stated resident (R1) refused assistance with daily needs such as showering and refused medications. Also R1 has refused medical assistance. LPA reviewed resident file at 10:50 am until 11:15 am. Administrator has notified the family and physician.
LPA and Administrator toured the facility at 12:00 pm until 1:00 pm. LPA did not observe any health or safety issues. Exit interview conducted and a copy of the report was given to the Administrator.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Melissa Spaeth
TELEPHONE:
(818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE:
11/17/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/17/2022
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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