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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 07:45:39 AM


Document Has Been Signed on 11/18/2022 07:45 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 FACILITYFACILITY NUMBER:
197610032
ADMINISTRATOR:JESSICA PELAYAFACILITY TYPE:
740
ADDRESS:44523 15TH STREET WESTTELEPHONE:
(661) 941-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:157CENSUS: 114DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jessica Pelaya TIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Spaeth conducted an annual visit and as greeted by Administrator. LPA's temperature was recorded and LPA observed the sign in station at the front entrance. LPA was also greeted by the receptionist and observed all staff were wearing masks. LPA and Administrator began the tour at 11:00 pm until 12:00 pm.

Dining Hall/Kitchen Area - LPA observed kitchen staff were preparing food for the lunch meal. LPA observed a seven-day supply of canned goods and dried goods. The walk in refrigerator contained a two day supply of fresh fruits, vegetables, eggs, and dairy products. The dining hall was clean and prepared for the noon meal.

Storage Room - LPA observed a 90-day supply of PPE items such as masks, surgical gowns, gloves, and masks. The room also contained an adequate supply of hygiene items.

Medication Room – LPA observed the medication room was locked and LPA observed med tech was preparing for the afternoon medication distribution.

Television Lounge – LPA observed residents watching television and observed a staff member was cleaning the room during LPA’s visit.

Administrative Office – LPA and Administrator entered the Administrative office at 12:15 am and observed additional PPE supplies and hygiene items.

Residents’ Rooms - LPA observed six rooms. Each room contained bed linens, night stand and night light. Each room has a bathroom and the four bathrooms contained, hand soap, paper towels and trash can. However, one resident stated had seen bed bugs in the bed. At 12:55 pm, LPA observed a bed bug in R1’s bed.

Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D.


Exit interview was conducted, appeal rights discussed and LPA gave a copy of the report during the visit.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (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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Document Has Been Signed on 11/18/2022 07:45 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary at all times. Maintenance shall include...mainte- nance services & procedures for the safety and well-being of residents. This requirement is not met as evidenced by:
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LPA observed bed bugs in R1's bed during LPA's tour of the facility, which is an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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