197610032-2-8-2024-31-AS-TAGD-D4PNC4-20240426102004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 02/08/2024
Date Signed: 02/08/2024 01:50:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
01/04/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20230104135833

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: 127	DATE:	02/08/2024
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained multiple pressure injuries due to staff's negligence

INVESTIGATION FINDINGS:

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Licensing Program Analyst Melissa Spaeth (LPA) conducted an unannounced subsequent complaint investigation for the allegation(s) listed above. LPA was greeted by the Administrator.

On 1/04/2023, a complaint was received by the Woodland Hills Adult & Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigation Branch as an assignment to investigate the complaint on 01/05/2023.

The investigation consisted of the following: On 01/06/2023, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested resident’s documentation, the resident roster, and the staff roster. During LPA’s visit, LPA received the requested documentation.

Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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-20230104135833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 02/08/2024

NARRATIVE

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A complete investigation was conducted by IB Investigator, Jose Santana. During the course of the investigation, Investigator Santana interviewed the administrator, resident(s), and staff members. Investigator Santana also interviewed a hospital staff member and received hospital medical records.

Regarding the allegation: Resident sustained multiple pressure injuries due to staff's negligence - It’s being alleged that a resident has multiple pressure injuries. Some of the pressure wounds were severe with dead skin tissue and were labeled as necrotic. It was reported that staff were not rotating the resident or helping the resident out of bed after the resident became bed bound.

Medical records revealed the resident had multiple wounds including unstageable pressure injuries to the left medial thigh, right hip, and left hip. Hospice and a wound specialist records stated the resident received care when the resident’s pressure injuries developed. The facility and hospice records indicate the resident developed a deep tissue pressure injury to the left medial thigh around 12/17/2022 and another DTPI on the resident’s right lateral hip on 12/20/2022. Between 12/20/2022 and 12/29/2022, the wounds became unstageable. Facility records indicated on 12/30/2022, the resident developed a new unstageable pressure injury on the resident’s left hip. Facility caregivers stated they repositioned the resident every two hours. However, the hospice nurse and wound specialist believe the resident’s comorbidities may have contributed to the development and progression of the pressure injuries due to staff not repositioning the resident every two hours. The resident stated facility staff members were only repositioning the resident two times per day.

IB Investigator interviewed the physical therapist on 2/28/2023 who stated that physical therapy was discontinued July, 2022 but stated the resident needed to continue physical therapy. The resident stated to the resident’s nurse practitioner that the resident was bed bound and wanted physical therapy. Facility staff denied being aware of the resident’s request. However, the facility did not ensure the resident’s physical needs were met. Due to the resident’s worsening leg contractures and increasing leg pain, the resident was unable to reposition themselves in bed. The resident experienced severe pain when caregivers attempted to reposition the resident which resulted in the resident’s refusal to be repositioned.

Per Title 22 Regulations, a facility may provide care to residents who have contractures, provided that “the contractures do not severely affect functional ability and care and/or supervision is provided by an appropriately skilled professional.” A facility is also required to keep a written record of care, including

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230104135833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 02/08/2024

NARRATIVE

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documentation from a physician of the contracture’s stability, and method of intervention. The facility retained the resident despite the resident’s leg contractures that kept them from walking, failed to ensure the resident received adequate intervention while on home health services, and did not keep a written record of the limited intervention they did receive.

The investigation revealed the facility contributed to the resident’s pressure injuries by not adequately addressing their contractures. The allegation that facility Neglect/Lack of Supervision contributed to the development of the resident’s pressure injuries is therefore substantiated.

An immediate Civil Penalty of $500.00 is being issued today, due to the staff’s negligence. Refer to LIC 421M. At this time an Enhanced Civil Penalty (ECP) determination is pending and may be assessed at a later date.

Exit interview conducted, appeal rights discussed, and a copy of the 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: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
01/04/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20230104135833

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: 122	DATE:	02/08/2024
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff did not provide proper incontinence care to resident in care

INVESTIGATION FINDINGS:

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Regarding the allegation: Staff did not provide proper incontinence care to resident in care - It’s being alleged that staff would only change the inserts of the diaper. LPA interviewed 10 of the 27 residents who need assistance with incontinent needs. All ten residents stated when changed by the caregivers the entire diaper is removed and that the staff never change the inserts of the diaper. LPA Spaeth also interviewed five of the ten caregivers who confirmed the entire diaper is removed when residents are changed.

Based upon the interviews of the residents and the staff, the allegation is unsubstantiated.

Exit interview conducted and a copy of the report was given.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20230104135833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/19/2024 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, ... those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 pressure injuries. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide staff training regarding proper documentation for repositioning residents in care. Administrator will provide staff sign in sheet for the training provided.
	8 9 10 11 12 13 14	Facility staff failed to adequately address the resident’s pressure injuries which poses an immediate health risk to persons in care.	8 9 10 11 12 13 14	During todays visit LPA issued a Civil Penalty of $500.
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	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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

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