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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:46:48 PM


Document Has Been Signed on 05/29/2024 04:46 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 132DATE:
05/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Jessica Pelaya (Administrator)TIME COMPLETED:
04:45 PM
NARRATIVE
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On 05/29/2024 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit in conjunction with complaint control #31-AS-20240524135605. LPA met with Administrator Jessica Pelaya and explained the purpose of the visit.


At approximately 10:35 a.m. LPA requested copies of documents in resident #1s (R1's) file. LPA reviewed the following: Identification and emergency information, Physician's Report, Preplacement Appraisal, Appraisal/Needs and Services Plan, various discharge paperwork, and Individual Service Plan. According to R1's records and interview with administrator R1's cognitive ability has declined. Furthermore, interview with Assisted Living Waiver Registered Nurse (RN) responsible for placement assistance corroborates R1 has had a change in condition which would require R1 to have a higher level of care. Review of physician's report revealed it was conducted in 2021. R1's Appraisal/Needs and Services Plan indicated it is an updated appraisal but does not have a date and does not include information relevant to residents current health condition and behavior R1 engages in.

Deficiency cited (refer to 809D). Exit interview conducted, appeal rights provided, and a copy of the report was given.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 04:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2024
Section Cited
CCR
87705(c)(5)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5)Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually... This requirement was not met by evidence of:
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Administrator will provide a copy of R1's medical assessment/physician's report and updated appraisal needs and services when completed to LPA by POC due date 06/10/2024.
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Based on interviews conducted with staff and residents and record review conducted by LPA, the licensee failed to have R1 receive an annual medical assessment which poses a potential health, safety, or personal rights risk to persons 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: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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