197610032-5-3-2024-31-AS-KCHN-D5T3KB-20240531181850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 05/03/2024
Date Signed: 05/03/2024 04:34:34 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
05/03/2024 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20240503093510

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: 128	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not ensure the facility is free from bed bugs.

INVESTIGATION FINDINGS:

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On May 3, 2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted an initial 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 investigate the complaint and report the findings for this complaint.

Regarding the allegation… Staff do not ensure the facility is free from bed bugs. it is being alleged a resident’s room (R1) had bed bugs. The room was sprayed but the bed bugs are still located in R1’s room.

LPA and a staff member toured the facility at 1:00 pm until 1:20 pm . The staff member and the LPA checked five rooms. LPA Spaeth checked an additional five rooms with other staff members at 1:25 pm until 1:40 pm. Five (5) out of the ten rooms (10) had bed bugs in the residents’ rooms and in residents’ beds.

LPA Spaeth interviewed the maintenance staff member (S1) at 2:00 pm until 2:20 pm. S1 stated a professional service sprayed each room during the month of January, 2024 and February, 2024.

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)

Page: 1 of 3

Control Number 31-AS-20240503093510

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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that time, S1 has been spraying residents’ rooms when there is a report of bed bugs within the rooms. S1 stated uses a product purchased at Home Depot. S1 confirmed only the rooms that have reported bed bugs are the rooms that have been sprayed during the month of March, 2024 and April, 2024. S1 also stated staff and residents will report to S1 when there are bed bugs and S1 will spray that particular room.

Based upon LPA’s observation of bed bugs in five residents’ rooms, 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)

Page: 2 of 3

Control Number 31-AS-20240503093510

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 B 05/10/2024 Section Cited HSC 87303(a)	1 2 3 4 5 6 7	87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary at all times. Maintenance shall include...mainte- nance services & procedures for the safety and well-being of residents, ....This is evidenced by:	1 2 3 4 5 6 7	Administrator agreed to request the professional service spray the entire facility.
	8 9 10 11 12 13 14	Based on LPAs observations and staff interview, the licensee did not comply with the section cited above by not ensuring the facility is free of bed bugs. 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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