197610032-5-8-2024-31-AS-NGID-D5XTRA-20240605145714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:15:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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 Lorena Casillas

COMPLAINT CONTROL NUMBER: 31-AS-20240503155205

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: 129	DATE:	05/08/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff mismanaged residents’ money.
Facility staff did not refill resident's medication in a timely manner.
Facility staff did not provide resident medication as prescribed.
Facility staff do not prevent residents from smoking in non-smoking areas.
The facility elevator is in disrepair.
Facility staff does not ensure facility is clean and sanitized.
Facility staff are not maintaining a comfortable room temperature for resident.

INVESTIGATION FINDINGS:

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On 05/07/2024 at 09:10 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with Administrator Jessica Pelaya and explained the reason for the visit.

At 10:00 AM LPA Casillas conducted a physical plant tour. During the investigation, interviews and record reviews were made from 11:00 am to 4:00 pm. LPA requested resident roster, Liability Insurance, Bond and LIC 500. LPA requested copies of pertinent information relevant to the investigation including but not limited to resident records, medication logs, elevator inspection certificates, maintenance logs and resident fund logs.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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 4

Control Number 31-AS-20240503155205

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 05/08/2024

NARRATIVE

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Allegation #1 Facility staff mismanaged residents’ money.

It is alleged that staff mismanaged residents’ money. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. LPA reviewed resident records and along with Assistant Administrator (AA) went over random resident money and logs. Upon review LPA discovered that there are no discrepancies regarding resident money, all receipts, funds and signatures are accounted for. Furthermore, interviews with residents revealed that they have no concerns regarding any funds missing or being withheld from them by the facility staff. Based on interviews, record reviews, and LPA's observation this allegation is deemed Unsubstantiated at this time.

Allegation #2 Facility staff did not refill resident's medication in a timely manner.

It is alleged that facility staff did not refill resident's medication in a timely manner. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. LPA reviewed resident medicine records and along with Staff #1 (S1) who is the Medicine Technician Supervisor, went over resident medication refill receipts. Upon review LPA discovered that there are no discrepancies regarding resident medication refills, all medication logs reviewed were accurate. LPA was informed by S1 that medications are delivered every night at around 7:00 pm Monday through Friday from Maggie’s pharmacy, which is the only pharmacy used for regular medicine refills. LPA was also informed by S1 that if residents need medication other than their regular medication that the local Rite Aid Pharmacy is used. Based on interviews, record reviews, and LPA's observation this allegation is deemed Unsubstantiated at this time.

Allegation #3 Facility staff did not provide resident medication as prescribed.

Continued on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20240503155205

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 05/08/2024

NARRATIVE

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Allegation #4 Facility staff do not prevent residents from smoking in non-smoking areas.

It is alleged that facility staff do not prevent residents from smoking in non-smoking areas. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. During facility tour LPA was able to observe there to be two (2) designated areas where residents are allowed to smoke outside in the patio. LPA did not observe any residents smoking inside the facility, nor were there any residents smoking in the rooms that LPA inspected. Furthermore, interviews with staff and residents confirmed that some residents do not follow the rules regarding smoking, however staff are diligent in instructing residents to designated areas and asking them to immediately stop smoking by putting cigarettes out. Based on interviews and LPA's observation this allegation is deemed Unsubstantiated at this time.

Allegation #5 The facility elevator is in disrepair.

It is alleged that the facility elevator is in disrepair. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. During facility tour LPA was able to observe that there are two (2) elevators in the facility. LPA was able to use both elevators and observed that they were last serviced on 12/06/2023 by Inspector # AH916, inspection expiration date is 12/06/2024. During LPA’s use of the elevators, they were both functioning properly, and alarms were audible. The elevators were clean and were functioning properly. LPA was informed by Staff #3 and Staff #4 that there is one resident that continuously spits as part of their behavior, therefore they have assigned two (2) shifts to specifically clean the hallways and the elevators. Elevators are cleaned at around 7:00 am, 12:00 pm, 2:00 pm and 9:00 pm. LPA was informed that in between those cleaning hours if elevators are visibly soiled, housekeeping will be called, and they are immediately cleaned. Based on interviews, record review, and LPA's observation this allegation is deemed Unsubstantiated at this time.

Continued on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20240503155205

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 05/08/2024

NARRATIVE

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Allegation #6 Facility staff does not ensure facility is clean and sanitized.

It is alleged that facility staff does not ensure facility is clean and sanitized. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. During facility tour LPA was able to observe that there were multiple staff members with portable cleaning carts throughout the facility performing their cleaning duties. LPA also observed that the facility was free and clear of clutter. LPA observed that the common areas, dining facilities, kitchen area, storage areas, and resident rooms that were inspected, were clean. Interviews with staff revealed that cleaning crew is split in two (2) shifts, 7:00 am to 2:00 pm and 2:00 pm and 9:00 pm, there is no cleaning staff from 9:00 pm to 7:00 am. Furthermore, interviews with residents revealed that their rooms are cleaned every day, multiple times a day if needed. Based on interviews, record review, and LPA's observation this allegation is deemed Unsubstantiated at this time.

Allegation #7 Facility staff are not maintaining a comfortable room temperature for residents.

It is alleged that facility staff are not maintaining a comfortable room temperature for resident. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. During facility tour LPA was able to observe that there were six (6) thermostats throughout the facility. The readings at 10:15 am were 67, 73, 74, 73, 73 and 74 degrees Fahrenheit. The facility upon entry was at a comfortable 73 degrees Fahrenheit and throughout the day it remained at 73 degrees Fahrenheit. LPA toured the facility again at 12:30 pm and the readings were 67, 73, 73, 74, 73 and 73 degrees Fahrenheit. LPA toured the facility one last time at 3:00 pm and the readings for temperature remained the same. The readings throughout the day stayed within regulation. Interview with Staff #2 (S2) revealed that every time there is a maintenance order, it is sent through an application on their phone where they can address the concern. S2 explained that once the concern is sent to their application the staff will begin to repair what is needed. S2 stated that they have not received a concern regarding the temperature being too hot. Based on interviews, records review, and LPA's observation this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4