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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 11/03/2023
Date Signed: 11/03/2023 01:20:22 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:
11/03/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Pelaya- AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Residents not provided with written notice of room changes
Use unsanitary laundry practices
Flooring in disrepair
INVESTIGATION FINDINGS:
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On 11/03/2023 Licensing Program Analyst (LPA) Mariana Agban arrived at the facility to conduct an
unannounced subsequent complaint investigation. Upon arrival, LPA was greeted by the administrator, and the purpose of the visit was explained.

Allegation: Residents not provided with written notice of room changes
It was alleged that residents have not been notified in writing regarding their move to other floors of the facility. Interview with the Administrator confirmed that residents have been notified only verbally regarding their move. LPA advised Administrator to provide written notices to all residents who will be moving to different areas in the facility. Based on observation and interviews the allegation is deemed Substantiated at this time
Allegation: Flooring in disrepair
During the physical plant tour on 10/23/23, LPA observed that floor in despair. LPA observed gaps in between the tile floor and cracks on the floor. (Continue on (9099C)
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: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
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 4
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: 11/03/2023
NARRATIVE
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Interview with the Administrator revealed that during the remodeling of the floor, the previous workers had done "a poor job" of attaching the new tile on top of the old tile. Administrator stated that they have already been in contact with a contractor to fix the issue. Based on observation the allegation is deemed Substantiated at this time.

Allegation: Use unsanitary laundry practices

It was alleged that clean linen carts were tied with trash bags. Interview with Administrator confirmed the allegation. Administrator stated that they have talked to staff about cross-contamination to prevent the bug transmission from one room to another. LPM Gillyard observed towels on the floor during the physical plant tour on 10/23/23. Administrator stated that they will implement a new protocol regarding soiled linen. Based on observation the allegation is deemed Substantiated at this time.

Exit interview conducted. Deficiencies cited 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: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
CCR
87468.2(a)(16)
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a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Administrator agreed to provide a statement of understanding for the regulation cited.
Administrator will send a blank copy of the 30-day advanced notification of room change notice they will using in the facility via email by the POC date.
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To written notice of any room changes at least 30 days in advance ... This requirement has not been met as evidenced by interviews the facility failed to provide written notices to residents which poses a potential safety risk to this resident in care.
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Type B
11/10/2023
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator agreed to provide pictures of fixed floor by the POC date.
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This requirement has not been met as evidenced by observation the facility has broken tiles which poses a potential safety risk to this resident in care.
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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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator agreed to provide a copy of the new protocol regarding soiled linens issued and signed by staff and email a copy by the POC date.
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This requirement has not been met as evidenced by observation the broken LPM observed towels on the floor which poses a potential safety risk to this resident in care.
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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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4