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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 03/08/2024
Date Signed: 03/08/2024 05:06:56 PM


Document Has Been Signed on 03/08/2024 05:06 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
CCLD Regional Office, 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: 130DATE:
03/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jessica Pelaya, Administrator TIME COMPLETED:
03:00 PM
NARRATIVE
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At 10;15am Licensing Program Analysts (LPAs) Angela Panushkina and Leslie Ngo-Castaneda, conducted a Case Management Visit in conjunction with the complaint #31-AS-20240301092942. LPAs met with the Administrator explained the reason for the visit.

At 11:40am, LPAs conducted visits to random resident rooms in an Assisted Living (2nd floor) and conducted an interview with ten (10) out of thirteen (13) residents. Upon entry to three (3) out of five (5) rooms LPAs noticed the following:
  • Toilet was not properly working in room #210
  • Bathroom flooring around the door frame in room #210 and #209 was damaged/chipped.
  • Room #209 had a broken dresser
  • Closet doors in room #210 and #218 were off the tack and damaged.
  • Window screen in room #225 was ripped.
  • Evacuation chairs on a second floor were missing

Deficiencies cited on LIC9099-D, based on LPAs observation of the physical plant.

Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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 03/08/2024 05:06 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
CCLD Regional Office, 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: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
87303(a)

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Maintenance and Operation: 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 is not met as evidenced by:
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Administrator agreed to submit proof of picture or an invoice with by POC date.
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Based on LPAs observation licensee did not comply with the section cited above, by not ensuring that three (3) out of five (5) resident rooms are in good repair. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
03/15/2024
Section Cited
HSC1569.695(f)(1)

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(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
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The licensee agreed to purchase the evacuation for each stairwell at the facility and will submit the proof of purchase to CCL on or before the POC date.
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Based on LPAs observation, the licensee did not comply with the section cited above by not having the evacuation chair in their stairwell, which poses/posed 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2