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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:39:08 PM


Document Has Been Signed on 01/10/2024 03:39 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: 122DATE:
01/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jessica PelayaTIME COMPLETED:
03:50 PM
NARRATIVE
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On 01/10/2024 at 2:14 p.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced case management - deficiencies visit in conjunction to complaint control number #31-AS-20240103123503. During complaint investigation, the following was discovered:

During interviews with staff it was revealed resident was sent to the hospital with an injury to his right hand and resident #1 (R1) had reported the injury was caused by an altercation with another resident. Staff report the administrator was notified but a special incident report was not submitted to the department. LPA could not find a report made by the facility in the regional office database. Administrator confirmed they did not submit a special incident report.


Deficiencies issued (refer to LIC809D). Civil Penalty assessed and issued (refer to LIC 421FC). Exit interview conducted. Appeal Rights provided. A copy of report was provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/10/2024 03:39 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: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2024
Section Cited
CCR
87211(a)(1)(D)

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87211(a) Each licensee shall furnish to the licensing agency... the following:(1)A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident... 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.
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Based on interview and record review the Licensee did not comply with the section cited above as evidence by a special incident report for R1 was not submitted to CCL which poses a potential 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2