197610032-11-4-2021-31-AS-MSPH-C8FVFN-20211104162409

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 11/04/2021
Date Signed: 11/04/2021 04:26:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 106	DATE:	11/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA Spaeth conducted an unannounced visit to the facility. LPA Spaeth's temperature was recorded and COVID questions asked upon arrival. LPA was greeted by Administrator, Jessica Pelaya at 11:35 am. LPA Spaeth began the tour with staff member, Vanessa Quintero at 11:50 am. LPA observed the COVID signs on the front door of the facility. Hand sanitizer was located near the entrance and LPA Spaeth observed five residents watching television. LPA was then escorted to the dining room and observed residents were eating a chili cheese hot dog with fresh salad. Both parties then walked into the kitchen and LPA observed three kitchen staff preparing the plates for the residents. LPA observed the refrigerator which contained dairy products such as eggs, milk, cheese and fresh vegetables. LPA then observed the freezer which contained frozen meats and vegetables. LPA observed the pantry which was slightly low of canned goods. Staff member Quintero stated the canned goods delivery is every Friday. While touring the first floor of the facility, LPA Spaeth observed two staff bathrooms which contained wash your hands sign, hand soap, paper towels, and a trash can. The public bathroom used by residents and visitors contained wash your hands sign, hand soap, and trash cans. However, the bathroom did not contain paper towels. Staff member Pelaya requested cleaning staff to supply paper towels in the bathroom. LPA observed four rooms on the first floor. Each room contained bed linens, night stand and night light. Each room has a bathroom and the four bathrooms contained wash your hands sign, hand soap, and trash can. However the bathrooms did not contain paper towels. Staff member Quintero discovered there was only one box of paper towels. At 12:30 pm, LPA met with Administrator and explained the paper towel shortage. Administrator stated

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/04/2021

NARRATIVE

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the paper towel supply is ordered by kitchen staff. Administrator stated will advise kitchen staff to order additional paper towel towels.

At 12:40 pm, LPA was escorted to the second floor by Staff member Quintero. LPA observed three rooms and observed all the rooms contained bed, linens, night lamp and night stand. However, the bathrooms did not contain paper towels. LPA also observed the second floor staff bathroom contained wash your hands sign, paper towels, hand soap, and trash can.

LPA then observed an adequate supply of hygiene items which were locked in the reception area. LPA was then escorted to the locked Administration office and observed PPE supplies which included masks, gloves, gowns, and hand sanitizer.

Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D.

Exit interview was conducted, appeal rights discussed and LPA gave a copy of the report during the visit.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/15/2021 Section Cited	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care ..of adequate hygiene practice shall be... available to each resident. (D)Clean linen,... bath towels, hand towels and wash cloths.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on LPA Spaeth's inspection of seven residents' rooms, there were no hand towels or paper towels provided for residents' use in each residents' bathroom.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

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