197610032-7-3-2024-31-AS-NMAN-D77TWR-20240715150559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:23:59 PM

Unsubstantiated

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
08/03/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230803121542

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: 132	DATE:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	Jessica Pelaya, Administrator		TIME COMPLETED:	04:27 PM

ALLEGATION(S):

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Staff did not refill resident's medication in a timely manner.
Staff did not dispense medication to resident as prescribed.
Staff do not prevent residents from smoking in non-smoking areas.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegations. LPA met with administrator, Jessica Pelaya, and explained the reason for the visit.

--- Staff did not refill resident's medication in a timely manner.

It was alleged that facility was out of insulin for Resident #1 (R1). To investigate the allegation, on 08/07/2023, LPA Antonia Alvizar-Ettima interviewed three (03) staff from 11:50 AM to 2:30 PM. On 07/03/2024, LPA Duguma requested documents at 10:30 AM, interviewed two (02) staff from 11:30 AM – 12:30 PM and interviewed thirteen (13) residents from 12:30 PM – 2:30 PM. A review of R1’s Medication Administration Records indicates R1’s insulin was self-administered during the month in question. During interviews with staff, all staff stated residents are issued medications timely and as prescribed.
(CONT on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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-20230803121542

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: 07/03/2024

NARRATIVE

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Staff #2 (S2) stated insulin is not refilled every month by corresponding with the primary care physician or the pharmacy, rather it is on a cycle and routinely refilled without anyone having to request for a refill and at no time did the resident not have access to or receive insulin. S2 stated resident was admitted to the facility on 06/02/2023 and received the first dose at the facility on 06/03/2023. S2 added that the insulin R1 was admitted to the facility with was a two (02) month supply and lasted until the first refill on 08/02/2023. During interviews with residents, all residents stated their medications are refilled in a timely manner.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff did not dispense medication to resident as prescribed.

It was alleged that Resident #1 (R1) is to take insulin three (03) times a day but it was not dispensed as prescribed. To investigate the allegation, on 08/07/2023, LPA Antonia Alvizar-Ettima interviewed three (03) staff from 11:50 AM to 2:30 PM. On 07/03/2024, LPA Duguma requested documents at 10:30 AM, interviewed two (02) staff from 11:30 AM – 12:30 PM and interviewed thirteen (13) residents from 12:30 PM – 2:30 PM. A review of R1’s prescription documents indicate a change in dosage from three (03) times a day to once a day before bedtime. A review of the Medication Administration Record indicates that R1 self administered the insulin at 9:00 PM. During interviews with staff, all staff stated residents are dispensed medications as prescribed. During interviews with residents, all residents stated their medications are dispensed as prescribed.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff do not prevent residents from smoking in non-smoking areas.

It was alleged that the facility’s hallways smell like marijuana and R1’s roommate smokes cigarettes in the room. To investigate the allegation, on 08/07/2023, LPA Antonia Alvizar-Ettima interviewed three (03) staff from 11:50 AM to 2:30 PM.
(CONT on LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230803121542

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: 07/03/2024

NARRATIVE

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On 07/03/2024, LPA Duguma conducted a physical plant tour and requested documents at 10:30 AM, interviewed two (02) staff from 11:30 AM – 12:30 PM and interviewed thirteen (13) residents from 12:30 PM – 2:30 PM. During the physical plant tour, LPA did not experience any marijuana or cigarette odor throughout the facility. During interviews with staff, all staff stated residents do not smoke marijuana or cigarettes in the facility and are not aware of R1’s roommate smoking cigarettes in their room. During interviews with residents, all residents stated they are not aware of marijuana or cigarettes being smoked anywhere in the facility.

Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

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