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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 10/27/2023
Date Signed: 10/27/2023 05:10:34 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
10/23/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20231023143942
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: 120DATE:
10/27/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica Pelaya- AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Hazardous equipment left accessible to residents in care.
Use of locked/delayed egress/digress without required fire clearance.
Use of common bathing implements

INVESTIGATION FINDINGS:
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On 10/27/23 Licensing Program Analysts (LPA) Mariana Agban and Licensing Program Manager (LPM) NIchelle Gillyard and Regional Manager (RM) Angela Kendrick arrived at the above facility to conduct initial complaint visit. Licensing team was joined by Caren William LTCOP and upon entrance met with the Administrator and explain the reason of the visit. At approximately 9:45 AM Licensing team and LTCOP conducted a physical plant tour, to ensure health and safety of the residents are protected with Title 22 Regulations.

Allegation: Hazardous equipment left accessible to residents in care.
It was alleged that facility used propane tanks in residents room for bedbugs treatment. Interview with the administrator confirmed the use of propane tanks to treat bedbugs. Licensing team advised Administrator to hire a licensed company to treat bedbugs and other pests issues. Administrator stated that all propane tanks were used in empty rooms where residents were out of the room. Administrator additionally stated that the propane tanks are currently locked in the maintenance room and residents have no access to them.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
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)
Page: 1 of 5
Control Number 31-AS-20231023143942
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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Allegation: Use of locked/delayed egress/digress without required fire clearance.
It was alleged that the second floor has egress door that was locked preventing residents and staff to enter and or exit. LPA file review revealed that facility has not obtained fire clearance for egress/digress door. Interview with the Administrator revealed that LIC200 has not been submit to CCLD at this time and the door was installed about a month ago.

Allegation: Use of common bathing implements.
It was alleged that the facility uses the same loofa for the residents in the shower room. Licensing team observed there's only one loofa is being used in the shower room during the physical plant tour. It was also observed same towels being used for multiple residents and an open trash can without lid and unclean shower floor without nonskid mat in the shower.

Due to time constrains LPA is unable to complete the investigation. The Administrator was informed that
additional visit will follow to render final findings. Exit interview conducted. Deficiencies and civil penalty issued and copy of this report delivered.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
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)
Page: 2 of 5
Control Number 31-AS-20231023143942
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
87309(a)
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Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by:
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Administrator agreed to lock all the propane tanks and hire a professional company to treat pests issue.
Type A
10/30/2023
Section Cited
CCR
87705(k)(2)
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87705(k)(2)The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of delayed egress devices.
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Administrator agreed to sumbit LIC 200 by the POC date and email the LPA a copy of complete LIC 200.
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This requirement has not been met as evidence by LPA's observation. Facility failed to notify CCLD and provide a complete LIC 200 form within the appropriate time frame
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CCR
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
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)
Page: 3 of 5
Control Number 31-AS-20231023143942
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
87307(a)(3)(C)
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(a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply:
(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident
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Administrator agreed to purchase new non skit matts and provide picture of new loofahs/bath cloths for residents and provide enough towels for the capacity of the facility and trash pins with lids in the shower rooms.
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 The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: based on LPAs obervation the facility failed to provide hygine items to residents.
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 Administrator will submit to LPA a proof of purchase and a picture of towels and loofas by the POC date
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
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)
Page: 4 of 5