197610032-10-27-2023-31-AS-MVAO-D47QCG-20240410120304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 10/27/2023
Date Signed: 10/27/2023 05:03:19 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20231025133939

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: 120	DATE:	10/27/2023
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	05:02 PM

ALLEGATION(S):

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Due to insufficient staffing residents' needs are not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with administrator Jessica Pelaya and explained the reason for the visit.

A physical plant tour was conducted by Regional Manager (RM) Angela Kendrick, Licensing Program Manager (LPM) Nichelle Gillyard, LPA Mariana Abagan and Long Term Care Ombudsman (LTCO) Caren Williams on 10/27/2023 at 9:40 a.m. for this complaint and complaint control #31-AS-20231023143942.

Allegation #1: Due to insufficient staffing residents' needs are not being met. It is alleged that the facility is short of staff and therefore are not meeting residents' hygiene needs. During the physical plant tour LPM Gillyard observed resident #1(R1) in bedroom #250A lying on soiled bedsheets. R1's under garments were observed to be soiled. Interview with administrator revealed assistance for R1 had not been provided since staff was busy assisting another resident. (Continued on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20231025133939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/27/2023

NARRATIVE

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(Continued from LIC9099)
LPA's review of Unusual Incident Report submitted by administrator to Community Care Licensing (CCL) revealed R1 had a change in condition and now requires assistance with incontinent care. LPM observed one (1) staff on duty in the designated memory care unit which houses twenty-five (25) residents, of which fifteen (15) have cognitive impairment according to the administrator. Staff #1(S1) had to call another staff not already in the memory care unit for assistance. LPM interview with S1 revealed S1 is a med-tech and a caregiver. At the time of the interview S1 was working in the capacity of a med-tech and not as a caregiver. In addition, LPM observed resident #2 (R2) in room #109 calling out for assistance requesting assistance with incontinent care. LPA's review of Unusual Incident Report submitted by administrator revealed R2 had a change in condition and now requires assistance with incontinent care. LPA Rios interview with administrator Jessica at approximately 11:50 a.m. revealed staff are expected to log the times they assist residents with bathing. According to Jessica residents that require assistance with bathing, are bathed twice a week. According to Jessica, staff have been known to not document consistently when they assist residents with hygiene. The facility uses an electronic database Caring Data to log hygiene assistance provided to residents.

Based on observation, record review and interviews conducted, the above allegation is found to be SUBSTANTIATED at this time. Deficiencies cited (refer to 9099-D).

Exit interview was conducted with administrator. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20231025133939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/30/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administrator agreed to (1.) submit a staff schedule that addresses the supervision of residents in the memory care unit. When applicable resident’s care plans shall be updated, and staffing scheduling shall be reevaluated. (2.) Submit proof of future staff training i.e., needs and services of residents, resident care, and supervision.
	8 9 10 11 12 13 14	Based on observation, record review and interviews conducted, facility staff failed to meet the needs of resident (R1) and (R2) who required incontinant care and S1 was the only staff observed in the memory care unit to provide assistance which poses an immediate safety risk to this resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC9099 (FAS) - (06/04)

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