197610032-1-10-2024-31-AS-RORN-D5SQ5J-20240531115201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:31:42 PM

Unsubstantiated

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
01/03/2024 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20240103123503

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: 122	DATE:	01/10/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not ensure a safe environment for resident in care.

INVESTIGATION FINDINGS:

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On 01/10/2024 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit for the above allegation. LPA arrived at 10:00 a.m. and met with Administrator, Jessica Pelaya. LPA explained to Jessica the reason for the visit. An entrance interview was conducted.

At 10:26 a.m. LPA interviewed the weekend administrator designee Edgar Cruz present during the incident in question. At approximately 10:35 a.m. LPA conducted a physical plant tour of the facility and interviewed resident #3 (R3) and resident #4 (R4) who may have information pertaining to residents in question (resident #1 (R1) and resident #2 (R2)). At approximately 11:20 a.m. LPA Rios obtained and reviewed copies of residents' record, resident roster and staff roster. At approximately 11:30 a.m. LPA conducted interviews with seven (7) other residents. At approximately 1:00 p.m. LPA interviewed R1's relative and staff #1 (S1).
Allegation: Staff did not ensure a safe environment for resident in care. It is alleged resident #1 (R1) was hit on the head repeatedly by resident #2 (R2). (Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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-20240103123503

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: 01/10/2024

NARRATIVE

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Interview conducted with the weekend administrator Edgar Cruz revealed R1 had reported to staff, R2 had hit R1 on the head with a stick 11 times. According to Edgar, R1 reported the incident and R1 had a wound on his right hand so the facility sent R1 to the emergency room to receive medical attention. Edgar reported R1 was not observed to have injuries on their head or bleeding from their head. Edgar reported he interviewed R2 and R2 denied hitting R1. According to Edgar the police arrived to the facility and after they were done questioning the residents, they requested the facility separate the residents. According to Edgar their where not witnesses to the incident. LPA contacted R1, R1 states they were hit by their roommate. R1's relative informed LPA, R1 had mentioned in November that their roommate was already causing trouble. LPA attempted to interview R2, but R2 had moved out of the facility on 01/09/2024 and did not leave contact information. Interview with R1's current roommate R3, revealed they have been hit on the back by R1 without provocation and could not recall if they had reported it to staff. Interview with R2's last roommate, R4, revealed they did not have any physical or verbal altercations with R2 prior to R2's departure. R4 revealed R2 would come to the room "drunk'' and would sleep most of the time. Interview with administrator corroborates R2 would return from the community inebriated. Interview with the administrator Jessica revealed they were not present during the incident in question and had heard about it afterwards. Administrator did not want to infer if R2 did or did not hit R2 on the head but denied the allegation the facility did not ensure a safe environment for resident in care. According to the administrator R1 was temporarily removed from the room as a precaution and eventually R2 agreed to move to a different room. According to administrator their has been no incidents involving R1 and R2 prior to the one mentioned on this complaint. LPA's interview with other residents did not corroborate the allegation. LPA Rios review of the discharge paperwork dated 12/09/2023, did not report any head injuries on R1. Based on the information obtained, LPA could not find a corroborating witness to the incident. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Exit interview conducted. No deficiencies were cited. A copy of the report was provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

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