197610032-5-4-2024-31-AS-MCAA-D4XU48-20240504151442

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 05/04/2024
Date Signed: 05/04/2024 03:15:19 PM

Document Has Been Signed on 05/04/2024 03:15 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 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: 129	DATE:	05/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Jessica Pelaya and explained the reason for the visit. At approximately 09:30am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. Currently there are ten (10) residents receiving hospice care and seventy (70) residents on the Assisted Living Waiver (ALW). The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. The smoke detectors were last serviced 09/23/23. Facility also have a functional sprinkler system. There are fire extinguishers located throughout the facility hallways. The charge date for the fire extinguishers was 11/30/23. The Fire Inspection was last held on 07/25/23. Kitchen: The kitchen is industrial. Appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food properly stored. Knives were stored and locked. Bedrooms: The facility has two floors. The first floor has fifty-two (52) shared bedrooms and the second floor has sixty-four (64) shared bedrooms. Random rooms were inspected and LPAs observed appropriate beddings and linens with sufficient lighting. Bathrooms: Each resident unit on both floors have their own bathrooms. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was between 105-107 degrees Fahrenheit. No cleaning supplies observed stored in resident bathrooms.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

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

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
	VISIT DATE: 05/04/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Common Areas: These includes the activity room, tv room, beauty shop and dining area. The common areas were properly furnished. The furniture were in good repair. Hallways and passageways are free of obstruction. The front door has a delayed egress. Per STD 850, fire-clearance for delayed egress and secured locked perimeter was approved on 07/30/20.

Surrounding Grounds: Entry/exits and hallways on the first and second floor were free of obstruction. Toxins and cleaning supplies stored and inaccessible during inspection. There is patio furniture appropriate for outdoor use. The outdoor area was free of hazards.

Laundry Room: There is a laundry room located on both the first and second floors. Laundry room is kept locked at all times.

Resident Files: Resident files are maintained in the administrator's office. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are maintained at the business office. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication Room is located near the administrator's office. Medication room is locked at all times. Medication and Medication Records were review for proper documentation.

Office/Work Station: The administrator's office is located near the front entrance, near check-in, and the business office is located at the right corner, front side of the building. Staff records and two computers, for staff use, were maintained in the business office.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2