197610032-7-29-2021-31-AS-CHAS-C6AMWF-20210827095816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 07/29/2021
Date Signed: 07/29/2021 05:18:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/31/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20201231171359

FACILITY NAME:	LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY		FACILITY NUMBER:	197610032
ADMINISTRATOR:	LABELLA, MARK J		FACILITY TYPE:	740
ADDRESS:	44523 15TH STREET WEST		TELEPHONE:	(661) 941-4578
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	157	CENSUS: 111	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Tanny Que		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained injury while in care.

INVESTIGATION FINDINGS:

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LPA Spaeth conducted a complaint visit and met with Tannya Quezada , Administrator Designee at 4:00 pm. LPA Spaeth discussed the purpose of the visit was to report the findings of the investigation regarding the complaint dated December 31, 2020. The complaint stated a resident sustained injury while in care. The complainant stated the resident had multiple large purple and red areas of bruising to the upper chest and stated the resident had long linear red areas of bruising along the neck.

The complaint report was forwarded to the Investigative Bureau via fax. A full investigation was conducted by IB Investigator, Peter Zertuche, for the case. The IB Investigator interviewed the Complainant on January 25, 2021. Complainant stated noticed numerous marks and bruises on resident’s chest and shoulder. The complainant reported resident was intubated and resident was unable to answer questions. Resident’s health declined and complainant stated the resident passed away

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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-20201231171359

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 07/29/2021

NARRATIVE

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on December 31, 2020. Complainant stated the injuries appeared suspicious but was unsure as to the resident’s past history and the cause of death was unknown but appeared to be unrelated.

Tannya Quezada, Administrator Designee for the facility was interviewed by IB Investigator on January 26, 2021. Administrator Designee stated facility staff were aware of the bruising and noticed bruising when resident returned from a Kaiser Hospital visit prior to resident’s hospitalization at the Antelope Valley Hospital. Administrator Designee contacted Kaiser regarding the bruises, but Kaiser staff stated they were unable to locate documentation regarding the doctor’s visit. Administrator Designee stated resident was diagnosed with cancer and severe anemia. Administrator Designee also stated the resident was taking blood thinner medications. Administrator Designee stated the resident had not been hit by any staff member and there was no report of a fall.

IB Investigator interviewed a caregiver who stated noticed resident’s bruising and reported the bruising to the Medication Technician at the facility. The Medication Technician then confirmed with the caregiver the resident sustained the bruising due to a blood transfusion at the hospital. Ted Bonzon, the Licensee for the facility was interviewed on Mach 8, 2021. Licensee stated resident refused to take medications on numerous occasions.

IB Investigator interviewed one of the resident’s treating physicians from the hospital on March 9, 2021. The doctor stated the resident arrived on December 24, 2020 and recalled treating the resident and noticed bruising. The doctor and peers reviewed the case and concluded that the cause of the bruising could have been due to the IV. The doctor also stated the resident was diagnosed with leukemia and was on blood thinners which caused the resident to bruise very easily.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20201231171359

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 07/29/2021

NARRATIVE

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In conclusion, the facility reported no unusual incidents and stated that the bruises may have been caused due to the victim’s illness and IV attempts. Medical records indicate the cause of the injuries may have been due to IV and low platelets which was confirmed by the admitting doctor who reported the victim had IV placed in the areas of bruising and was diagnosed with leukemia, was on blood thinners and bruised easily. The IB Investigator concluded the findings are unsubstantiated.

An exit interview was conducted, and a copy of the report sent to Administrator Designee requesting the Administrator Designee’s signature. LPA Spaeth requested signed copy of the report be sent to LPA via email

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

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