197610032-5-3-2024-31-AS-TAGD-D5HPAT-20240522110915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 05/03/2024
Date Signed: 05/03/2024 04:36:18 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
12/13/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20221213113305

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: 130	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident eloped from the facility

INVESTIGATION FINDINGS:

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On May 3, 2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to deliver findings for this complaint.

The investigation consisted of the following: On 12/14/2022, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested documents. LPA Spaeth requested the following documents: 1) resident roster, 2) incident reports dated 12/06/2022, and 3) R1’s physician’s report. All documents were received at the time of visit. LPA Spaeth conducted interviews with two staff members, and the Administrator. LPA Spaeth attempted to interview R1 on 08/04/2023; however, R1 declined.

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: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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-20221213113305

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: 05/03/2024

NARRATIVE

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Regarding the allegation… Resident eloped from the facility. It is being alleged the resident eloped from the facility on 12/06/2022 without staff members’ knowledge. The reporting party called the facility on Tuesday, 12/06/2022 and asked to speak to R1. The reporting party was told by staff R1 was sleeping. The reporting party called again on Thursday 12/08/2022 and staff told the reporting party R1 left the facility without staff member’s knowledge.

During interviews with the two staff members (S1 and S2), S1 and S2 confirmed they worked the morning of 12/06/2022. S1 and S2 confirmed Room 103 was unlocked. S1 and S2 confirmed Room 103 was used for storage. Upon entering the room, S1 and S2 observed the door leading to the outside of the facility was open. S1 and S2 confirmed the Administrator has stated to all staff Room 103 must remain locked at all times since an exit door leading to the outside is located within that room.

When S1 observed the side door was open, S1 sent a snapshot of the open door to Administrator. The Administrator confirmed the resident had eloped the morning of 12/06/2022. The Sheriff’s Department was called and the Department filed a missing person’s report. LPA Spaeth observed the report was dated 12/06/2022. LPA Spaeth reviewed the 12/06/2022 incident report that was sent to CCL regarding the elopement of R1. The report revealed S1 and S2 observed the side exit door was open. The report also stated S1 and S2 conducted a head count and discovered R1 was not at the facility. The Administrator confirmed the staff called the Administrator on 12/06/2022 confirming R1 was not in the facility. LPA Spaeth reviewed R1’s Physician’s Report (LIC 802) dated 08/28/2020 which revealed R1 would need to be accompanied with staff if R1 left the facility.

Based upon LPA’s interviews and review of R1’s LIC 802 dated 8/28/2020, the allegation is substantiated.

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: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20221213113305

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: 05/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/06/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and ….furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to providing a sign in sheet for all staff stating all exit doors will be checked at the beginning of each shift.
	8 9 10 11 12 13 14	Based on LPAs interviews, the licensee did not comply with the section cited above by not ensuring the storage room door was locked. The door was unlocked and R1 left the facility unassisted by staff. This poses a potential health, safety or personal rights risk to persons 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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

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