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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 09/15/2023
Date Signed: 09/15/2023 04:03:22 PM


Document Has Been Signed on 09/15/2023 04:03 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
WOODLAND HILLS S.ASC, 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: 118DATE:
09/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica PelayaTIME COMPLETED:
03:15 PM
NARRATIVE
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LPA Melissa Spaeth and LPA Lorena Casillas conducted an unannounced visit regarding Complaint and #31-AS-20221130114717. LPAs were greeted by Administrator at 9:05 am.

LPAs toured the facility at 9:00 am until 10:00 am with the Administrator and observed the following:

1) At 10:20 am, LPAs observed part of the flooring located on the north side of the hallway was missing. The floor panels had been removed and were stacked in a corner. LPAs observed the floor was uneven and some shredding of the panels were still attached and poses a hazard for residents.

2) At 10:25 am, LPAs observed the toilet tank top was missing in the public bathroom #1.

3) At 10:40 am, LPAs entered the kitchen and observed a large puddle of water was on the floor near the industrial dishwasher. LPAs observed a water leak which was running to the floor. The kitchen staff were unable to stop the flow of water.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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 09/15/2023 04:03 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
WOODLAND HILLS S.ASC, 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: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2023
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (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 is evidenced by
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Administrator will email a snap shot of the repairs completed.
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LPA's observed the floor panels had been removed making the floor uneven. The toilet tank cover was missing in bathroom #1. In the kitchen there was a large puddle of water on the floor coming from a leak in the industrial dishwasher. This poses an immediate health, safety, or personal rights risk to persons 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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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