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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:17:35 PM


Document Has Been Signed on 12/20/2023 04:17 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: 126DATE:
12/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jessica PelayaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator. LPA Spaeth stated the purpose of the visit was to confirm the facility has completed the Fire Inspector, Jay Marietta’s request for the following procedures be completed by December 18, 2023.

- Maintain records of periodic testing and maintenance of the fire alarms. LPA received a copy of the Inspection, Testing and Maintenance Cover Sheet from the contractor, Fletcher’s Fire Protection dated July 25, 2023 which is documentation confirming the fire alarm had been tested.
- At 3:45 pm LPA observed the mid hallway doors that were installed on the second floor were removed.
- AT 3:50 pm, LPA observed the inspection/license sign was displayed.

There are no deficiencies to report at this time. Exit interview conducted and a copy of report was given.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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