<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 11/12/2021
Date Signed: 11/12/2021 04:42:30 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 FACILITYFACILITY NUMBER:
197610032
ADMINISTRATOR:LABELLA, MARK JFACILITY TYPE:
740
ADDRESS:44523 15TH STREET WESTTELEPHONE:
(661) 941-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:157CENSUS: 113DATE:
11/12/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica PelayaTIME COMPLETED:
10:00 AM
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 and was greeted by Administrator, Jessica Pelaya. LPA Spaeth stated the purpose of the visit was to conduct the plan of correction visit regarding LPA's November 4, 2021 annual visit. LPA had observed seven resident bathrooms and observed the bathrooms did not contain paper towels.

During today's tour of the facility, LPA Spaeth and Administrator checked eleven resident bathrooms from 9:30 am until 9:45 am and LPA observed paper towels in each bathroom. At 10:55 am, LPA observed three large boxes of paper towels within the storage area of the facility are available for resident use. Administrator stated has instructed kitchen staff to make sure order for supplies is completed within a timely manner.

LPA Spaeth concluded the POC tour and advised Administrator the deficiency was cleared. At 11:05 am, LPA sent the POC letter via email to the Administrator.

There are no additional deficiencies to report at this time. Exit interview conducted, appeal rights discussed and a copy of the signed report was given to the Administrator.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1