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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610032
Report Date:
04/12/2024
Date Signed:
04/12/2024 03:24:45 PM
Document Has Been Signed on
04/12/2024 03:24 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 FACILITY
FACILITY NUMBER:
197610032
ADMINISTRATOR:
JESSICA PELAYA
FACILITY TYPE:
740
ADDRESS:
44523 15TH STREET WEST
TELEPHONE:
(661) 941-4578
CITY:
LANCASTER
STATE:
CA
ZIP CODE:
93534
CAPACITY:
157
CENSUS:
130
DATE:
04/12/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Jessica Pelaya
TIME COMPLETED:
03:15 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 regarding an incident report and death report received by Community Care Licensing.
Community Care Licensing received an incident report dated 4/09/2024 stating a resident passed way on 4/09/2024 at 6:20 am.
LPA Spaeth reviewed resident's file (R2) from 1:50 pm until 2:15 pm. LPA received copies of the documents. LPA interviewed a resident and one staff member at 2:10 pm until 2:30 pm.
LPA Spaeth will be conducting additional staff interviews and will return to the facility at a later time.
Exit interview conducted and a copy of the signed report was given.
SUPERVISOR'S NAME:
Troy Agard
TELEPHONE:
(818) -596-4334
LICENSING EVALUATOR NAME:
Melissa Spaeth
TELEPHONE:
(818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE:
04/12/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/12/2024
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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