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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 02/22/2023
Date Signed: 02/22/2023 04:10:19 PM


Document Has Been Signed on 02/22/2023 04:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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: 112DATE:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jessica PaylaTIME COMPLETED:
04:20 PM
NARRATIVE
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On 2/22/2023 Licensing Program Analysts (LPAs) Evelin Rios and Melissa Spaeth conducted a case management deficiencies visit in conjunction to complaint control #31-AS-20230213132242.

At 9:10 a.m. during an interview with the Administrator, it was revealed a resident #1 (R1) had a bad day and shoved her. R1 was taken to the hospital for evaluation, R1's guardian was notified and a police report was completed. According to the administrator R1 was admitted to a hospital in San Bernardino County. LPAs asked administrator if an incident report was submitted to Community Care Licensing Division (CCLD) regional office. Administrator said, "no". At 9:27 a.m. LPAs conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. At 9:47 a.m. while touring the kitchen LPAs observed food supply did not meet the required number of nonperishable food for a minimum of one week & perishable foods for a minimum of two days maintained on the premises. According to staff #1 (S1) who is responsible for food purchasing, they had a list of grocery items on their phone, they were going to purchase on today's date. S1 stated they were also going to make purchases at "Cotsco". At 9:58 a.m. LPA observed a large water spot on a ceiling tile in room 117. Upon further observation the tile was drooping to the point of almost falling down. Administrator stated they had not seen it there before. Resident #2 (R2) stated it was there when they moved in. R2 also stated it was not leaking. Administrator immediately notified maintenance to take care of it.

Deficiencies cited (refer to LIC 809-D). Civil Penalty assessed and penalty issued (See LIC 421FC). Exit interview conducted, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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 02/22/2023 04:10 PM - 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
N LA & CEN COA AC/SC, 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: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/24/2023
Section Cited
CCR
87555(b)(26)

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(b) the following food service requirements shall apply: (26) Supplies of nonperishable food for a minimum of one week & perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
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Licensee/Administrator will purchase groceries to meet the minimum requirement on the regulation cited and send a picture of receipt and groceries to LPA by POC date 02/24/2023.
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Based on observations by LPA the Licensee did not comply with the section cited above by not ensuring the required minimum of 7-days nonperishable and 2 days perishable supply of food was maintained on the premises. This poses an immediate health and safety or personal rights risk to clients 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/22/2023 04:10 PM - 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
N LA & CEN COA AC/SC, 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: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited
CCR
87211(a)(1)(D)

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(a) Each licensee shall furnish...(1)A written report...(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents...This requirement was not met as evidenced by:
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Administrator will submit an incident report for the incident described on this report and a written statement that all incident reports will be reported in a timely manner by poc due date 03/03/2023.
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Based on interview and record review the Administrator did not comply with the section cited above as evidence by the administrator's own admission an incident report was not submitted to Community Care Licensing Division (CCLD) when R1 shoved her and R1 was taken to the hospital.
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Type B
03/03/2023
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors...This requirement was not met as evidenced by:
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Licensee/Administrator will ensure in house maintenance repair ceiling tiles in R2's bedroom. A picture of the fixed ceiling submitted to LPA by POC date 03/03/2023.
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Based on interviews and observation, conducted by LPA the licensee did not comply with the section cited above by failing to maintain resident's #2 (R2) room in good repair. Ceiling tile in R2's room 117 is drooping.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3