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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 03/01/2024
Date Signed: 03/04/2024 08:04:33 AM

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
10/21/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20221021140132
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: 131DATE:
03/01/2024
UNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Crystal BarrientosTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for a resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Melissa Spaeth and Evelin Rios conducted an unannounced complaint visit to the facility. LPAs met with the Administrator Assistant and explained the purpose of the visit is to deliver the findings regarding the allegations listed above. An entrance interview was conducted.

On 10/21/2022, a complaint was received by the Woodland Hills Adult & Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigation Branch (IB) on 10/21/2022 for a full investigation and was accepted on 10/21/2022.

On 10/26/2022, LPA Melissa Spaeth conducted an initial complaint visit. During the visit at 10:26 am, LPA conducted a review of resident records, reviewed Medication Administration Record Sheets (MARS) and at 11:30 am interviewed the Medication Technician Supervisor, a caregiver and the Administrator Jessica Pelaya.

ontinued on 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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-20221021140132
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: 03/01/2024
NARRATIVE
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The hospital records were subpoenaed and reviewed by IB investigator Heidy Bendana. On 11/30/22, IB Investigator Bendana conducted a complaint investigation visit to the facility at which time the investigator reviewed facility files and interviewed five (5) staff and three (3) residents.

Regarding the allegation: Staff did not seek timely medical attention for a resident in care. It’s being alleged that Resident 1 (R1) had experienced weakness, problems breathing and urinary discomfort for an unspecified period of time. Staff had knowledge of R1’s condition and did not seek medical attention. During the IB investigation, information was gathered through facility files, including resident records, and medical records. Interviews were conducted with potential witnesses and staff. During interviews, it was discovered that R1 had complained of stomach and abdominal pain for an unspecified time. R1’s urine output was very little. R1 was vomiting and was running a fever. Four (4) out of the thirty-three (33) staff members confirmed R1 was vomiting and had low output. One (1) staff member stated R1 was declining for about a week. Two (2) staff members stated R1 reported they were not feeling well and were in pain.

The Administrator confirmed they were aware of the medical conditions and health history of R1.
The Administrator also admitted that a staff member reported about R1 experiencing stomach pain and having minimal urine output. The Administrator stated they did not know the length of time R1 had been in pain. The Administrator then called home health who advised to send R1 to the hospital.

One (1) of the witnesses interviewed by IB indicated that based on R1’s health conditions and on low or little urine output, the issue should have been immediately addressed by a skilled professional or staff. If not addressed, the issue could lead to a urinary tract infection which can cause sepsis or a fever and also could cause low blood pressure.

The facility documents notated the resident complained of pain and discomfort. Based on interviews and record review, there is a sufficient information and/or evidence to support the allegation. Therefore, the allegation is substantiated.

Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiency was observed and cited during the visit. See LIC 9099-D.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20221021140132
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: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2024
Section Cited
CCR
87465(g)
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87465 Incidental Medical & Dental Care (g) The licensee shall immediately telephone 911 if an injury,... has resulted in an imminent threat to a resident’s health including,.. an apparent life-threatening medical crisis...This requirement was not met as evidenced by:
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The Administrator will develop and implement staff training regarding proper documentation of resident's decline in health and procedures in reporting the residents decline in health. Administrator will provide a staff sign in sheet when staff has completed the training.
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Based upon staff interviews, staff failed to call 911 when staff observed the resident had experienced pain and discomfort which poses an immediate health & safety risk to residents in care.
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Type A
03/12/2024
Section Cited
CCR
87466
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87466 Observation of the Resident.
The licensee shall ensure that residents are regularly observed for changes in... physical,..functioning &...assistance is provided... When changes...are observed, the licensee shall ensure that changes are brought to attention of resident's physician...
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The Administrator will develop and implement staff training regarding proper documentation of resident's decline in health and procedures in reporting the residents' decline in health. Administrator will provide a staff sign in sheet when staff has completed the training.
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This requirement was not met as evidenced by: Staff interviews revealed the changes in R1's health were not brought to the physician's attention in a timely manner, which poses an immediate health & safety risk to residents 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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
10/21/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20221021140132

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: 131DATE:
03/01/2024
UNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Crystal BarrientosTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not notice resident had bed bug bites
INVESTIGATION FINDINGS:
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Regarding the allegation: Staff did not notice resident had bed bug bites. It’s being alleged that R1 had bed bug bites & the bites were identified by hospital staff. On 02/22/2023, LPA Melissa Spaeth and LPA Evelin Rios conducted a subsequent complaint investigation visit. LPAs met with Jessica Pelaya. During the visit, at 11:30 qm LPAs Spaeth and LPA Rios interviewed six (6) staff members, the administrator, and thirteen (13) residents. At 12;00 PM, LPAs also toured ten (10) residents’ rooms with the maintenance staff. Information received revealed that R1 was admitted into Antelope Valley Medical Center on 10/20/2022. During the hospital intake, R1 was observed with bed bug bites all over their body, and the bed bug bites had to be treated, which caused a delay in R1 obtaining medical tests.

LPA Spaeth interviewed seven (7) out of the thirty-three (33) staff members. Six (6) of the seven (7) staff including the administrator denied observing bed bug bites on R1 and denied R1 reporting bites. Four (4) of the seven (7) staff members admitted seeing R1 scratching themself and stated R1 had wounds from the scratches. Thirteen (13) of the one hundred twelve (112) residents were interviewed denied having or seeing bed bug bites on other residents. Nine (9) out the thirteen (13) residents interviewed stated seeing bed bugs in their room in the past six months, but their rooms were sprayed. The nine (9) residents stated have not seen a bed bug since their room has been sprayed
Based on the interviews, inspection and observation, there is insufficient evidence to support the allegation. Hence, the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4