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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:39:16 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.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
09/29/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230929144615
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:
07/11/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica PelayaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident was raped by another resident in care.
Staff fail to meet resident's hygiene needs.
Staff failed to provide basic laundry services.
Staff cut resident's hair against their will.
Facility is infested with insects/pest.
Facility is in disrepair.
Staff fail to provide residents clean eating utensils.
INVESTIGATION FINDINGS:
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On 7/11/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a subsequent 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 conduct interviews and present findings.

LPA conducted a physical tour at 9:30 am until 10:30 am. LPA interviewed twelve (12) residents at 10:30 am until 11:30 am and interviewed four (4) staff members at 11:30 am until 11:45 am
The investigation consisted of the following: On 10/03/2023 LPA Spaeth initiated a complaint investigation. LPA reviewed the resident files. LPA received copies of the documentation. On 7/08/2024, LPA Spaeth conducted a second visit, interviewed eight staff members at 3:00 pm until 4:00 pm, and received additional resident documentation.

continued - 9099-C
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: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
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-20230929144615
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: 07/11/2024
NARRATIVE
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Regarding the allegation: Resident was raped by another resident in care. It’s being alleged that a resident was raped by another resident. LPA Spaeth interviewed eight caregivers/staff members (S1 to S8) and the Administrator who stated they have not witnessed this happen and a resident did not report to them this occurred. LPA Spaeth interviewed twelve residents (R1 – R12) who stated this did not occur to them, they did not witness this occurrence and also stated another resident did not inform them this happened. The resident mentioned in the complaint is no longer living at the facility and contact information was not provided to the facility staff when the resident moved out of the facility. Therefore, this allegation is unsubstantiated.

Regarding the allegation, Staff fail to meet resident's hygiene needs. It’s being alleged that the residents have not received showers, staff use the same loofah when assisting residents in the shower, and the loofah is never sanitized after each use. S1 – S8 unanimously stated when assisting residents with showering, a loofah is not used. A clean wash cloth and clean towel are used for reach resident. S1 – S8 also stated a shower schedule is followed each day. S1 – S8 are assigned specific residents with showering so that no one is overlooked. S1 – S8 also stated if a resident requests a shower each day, the staff are happy to accommodate their request. The Administrator stated the shower schedule was created to ensure all residents receive a shower twice a week. LPA Spaeth received a copy of the shower schedule.

During the facility tour at 10:15 am, LPA observed the shower room and there was no loofah in the room. Eight (8) out of the twelve (12) residents interviewed stated they receive assistance with showering and also unanimously stated a loofah is not used but a clean wash cloth and a clean towel are used. The eight (8) residents who receive assistance with showering stated they are assisted two times a week. The eight residents also stated staff never miss assisting them each week and stated if they ask for an additional shower day, the staff always accommodates their request. Therefore, the allegation is unsubstantiated.

Regarding the allegation, Staff failed to provide basic laundry services. Its being alleged that residents’ clothes and bed sheets have not been washed. It is also alleged that residents wear the same clothing for five days in a row. S1 – S8 stated the residents are encouraged to change their clothes each day and they have never witnessed a resident wearing the same clothes for five days in a row. S1 – S8 confirmed there is one caregiver who washes the residents’ clothing and bedding. S1 – S8 also confirmed the residents have not stated their bedding or clothing have not been washed. LPA interviewed the caregiver (S7) who confirmed they wash the residents’ clothing and bedding. S7 stated there are many times that a resident’s sheets might be washed more than one time a week due to accidents that occur in a residents' bed.

Continued 809-C

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

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230929144615
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: 07/11/2024
NARRATIVE
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LPA interviewed twelve residents (R1 – R12) who unanimously confirmed their clothing and bedding is washed every week. R1 – R12 also stated they do not walk around in the same clothing for five days. Therefore, the allegation is unsubstantiated.

Regarding the allegation, Staff cut resident's hair against their will. It’s being alleged that a staff member told a resident they must shave their head due to a medical condition. One (1) out of the twelve (12) residents interviewed stated they had a medical condition and the resident decided to have their head shaved in order to alleviate the medical condition. The resident discussed the possibilities with a staff member and the resident made the choice to have their head shaved. The staff member did not force the resident to shave their head. The other twelve residents stated they were never forced to shave their heads. S1 – S8 stated they never forced a resident to shave their head. Therefore, the allegation is unsubstantiated.

Regarding the allegation, Facility is infested with insects/pest. It’s being alleged there are bed bugs, roaches and spiders in the facility. Also it is alleged that a pest control company has not treated the facility. During LPA’s facility tour, LPA was escorted by the maintenance staff member. Both parties checked ten rooms at 10:00 am until 10:30 am. LPA did not observe any bed bugs, roaches or spiders. R1 – R12 stated the facility had a professional company spray the rooms. LPA Spaeth received a copy of the bed bug service documentation which proves each room was professionally fumigated on May 4, 2024. R1 – R12 unanimously stated there are no bugs in their rooms. Therefore the allegation is unsubstantiated.

Regarding the allegation, facility is in disrepair. It’s being alleged that there are holes and mildew on the walls. During today’s facility tour, LPA did not observe holes or mildew. Therefore the allegation is unsubstantiated.

Regarding the allegation, Staff fail to provide residents clean eating utensils. It’s being alleged staff do not dispose of plastic utensils after each meal. Also it is alleged staff are reusing plastic utensils without properly cleaning them. LPA Spaeth interviewed the three dining hall staff (R9 – R11) who unanimously stated the eating utensils are thrown away by residents after each meal. R9 – R11 stated they never reuse the used plastic utensils. All three unanimously stated there are fifty plastic forks in sealed bags. When the residents are served their meals, the sealed bags are opened and each resident receives clean utensils. The residents then dispose of the utensils. R1 – R12 all stated they dispose of the plastic utensils after every meal. Therefore the allegation is unsubstantiated.

Exit interview conducted and a copy of the signed report was given.

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

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3