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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 07/27/2021
Date Signed: 07/27/2021 04:39:07 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 FACILITYFACILITY NUMBER:
197610032
ADMINISTRATOR:LABELLA, MARK JFACILITY TYPE:
740
ADDRESS:44523 15TH STREET WESTTELEPHONE:
(661) 941-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:157CENSUS: 111DATE:
07/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Tannya QuezadaTIME COMPLETED:
03:45 PM
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LPA conducted a case management-incident report visit and arrived at 2:45 pm. LPA was greeted by Administrative Staff who was wearing a mask when LPA arrived. Administrator Designee, Tannya Quezada. greeted LPA.

LPA explained the purpose of the visit was to speak to Administrator Designee regarding an incident report. LPA Spaeth interviewed resident mentioned in incident report. LPA obtained the medication records of the resident. The incident report stated on July 25, 2021 a woman from the facility called 911 at 1:22 pm. Paramedics and the fire department arrived at the facility and informed staff a female had called stating had been raped three times. A police report was filed. LPA obtained a copy of the police report. Resident was asked if need to go to the hospital and Resident stated yes. Resident was sent to the hospital and she returned to the facility on the same day.

At 3:00 pm, LPA was escorted by Administrator Designee for a tour of the facility. LPA observed residents sitting in the television lounge watching television. LPA observed staff members cleaning the facility. LPA and Administrator walked through the kitchen and LPA observed staff members preparing the evening meal. The kitchen staff were wearing masks and stated the evening meal was pulled pork sandwiches. LPA observed the downstairs public bathrooms contained wash your hands signs, hand soap and paper towels. LPA was then escorted to the second floor and observed staff members were also cleaning the second floor residents' rooms. LPA also observed the second floor public bathrooms also contained hand soap, paper towels, and wash your hands sign.

LPA Spaeth concluded the tour at 3:30 pm. Exit interview conducted, and LPA confirmed will send signed report to Administrator Designee via email.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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