197610032-8-8-2026-31-AS-TAGD-DWWU9G-20260813152307

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 08/08/2026
Date Signed: 08/08/2026 11:21:11 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
04/14/2026 and conducted by Evaluator Angelica Segovia

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260414083041

FACILITY NAME:	LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY		FACILITY NUMBER:	197610032
ADMINISTRATOR:	CRYSTAL BARRIENTOS		FACILITY TYPE:	740
ADDRESS:	44523 15TH STREET WEST		TELEPHONE:	(661) 941-4578
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	157	CENSUS: 128	DATE:	08/08/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Crystal Barrientos- Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not prevent resident from smoking near oxygen resulting in a fire.
Resident sustained severe injuries due to staff neglect.
Staff did not ensure the facility phone was answered.
Staff are not providing adequate supervision for residents

INVESTIGATION FINDINGS:

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On 8/08/2026 at approximately 10:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit was to deliver the findings of the complaint.

On 04/14/2026 the Woodland Hills South Adult and Senior Regional Office received a complaint alleging the neglect and lack of care from the facility staff resulted in a resident sustaining injury due to a fire. On 4/14/2026, LPA Segovia conducted the initial twenty-four (24) hour complaint investigation visit. On 4/14/2026, the complaint was referred to the Community Care Licensing Investigation Branch and accepted as an investigation.

(continue to LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2026

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 4

Control Number 31-AS-20260414083041

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 08/08/2026

NARRATIVE

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The investigation determined the following:

Regarding the allegation: Staff did not prevent resident from smoking near oxygen resulting in a fire. It was alleged that staff did not prevent Resident 1 (R1) from smoking near an oxygen tank which resulted in a fire. To investigate the allegation, between the dates of 4/27/2026 to 5/07/2026, the Department conducted interviews with one (1) resident (R1) and three (3) staff members (S1-S3). The Department’s interview with R1 revealed on 3/25/2026 they were smoking a cigarette in their room while wearing their oxygen mask when they accidentally burned their face. R1 confirmed they had been “reprimanded” multiple times due to their insubordination regarding this issue. R1 confirmed the day of the incident there was no, “boom” nor did they catch themselves on fire. Per R1, staff check on them frequently every, “20-30 minutes”.

The Department’s interview with S1 revealed R1 had been given multiple warnings for being in violation of the house rules due to them smoking in their bedroom. Per S1, the day of the alleged incident (3/25/2026), R1 was taken to the hospital due to burn marks on their face. Per S1, they did not witness the incident but were informed by S2 who discovered R1 with what appeared to be red marks on their face, but no fire was present or observed. S1 stated when they questioned R1 as to what had occurred, R1 did not deny the fact that they were smoking in their room. Subsequently emergency services were called and R1 was transported to the hospital where they were treated for their burns on their face and discharged back to the facility.

The Department’s interviews with S2 and S3 correlated with S1’s interview. S2’s interview revealed once they observed what had occurred, R1 was assisted with medical care/services. On 4/28/2026, the Department received confirmation from the facility pertaining to R1’s warnings/write-ups and 30-day notice of eviction due to their numerous incidents of smoking in their bedroom.

Based on The Department’s interviews and the evidence collected, the Department’s findings of the complaint are UNSUBSTANTIATED at this time.

(continue to LIC 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20260414083041

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 08/08/2026

NARRATIVE

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Regarding the allegation: Resident sustained severe injuries due to staff neglect. It was alleged that R1 sustained severe injuries due to staff neglect. To investigate the allegation, on 5/07/2026, the Department conducted an interview with one (1) resident (R1). The Department’s interview with R1 revealed, on 3/25/2026 they were smoking in their room with their oxygen tank when they burned their face. R1 confirmed they did not catch themselves on fire. Additionally, R1 revealed staff check on them often, “…every 20-30 minutes…” and once staff was made aware, they were immediately helped.

On 4/23/2026, The Department subpoenaed R1’s medical record from Antelope Valley Medical Center. On 5/04/2026, the Department received R1’s medical records where the following was disclosed:

“PT was smoking w/O2 tank has burs to nose an upper lip w/signed nose hairs. No other injuries were noted…The pain is moderate and characterized as a burning feeling. There is no inhalation of smoke or fumes, and no associated headache, dizziness, shortness of breath, chest pain or palpitations. There is no pain internally in…nose, mouth, or throat…There is no facial swelling…”.

Based on The Department’s interviews and the evidence collected, the Department’s findings of the complaint are UNSUBSTANTIATED at this time.

Regarding the allegation: Staff are not providing adequate supervision for residents. It was alleged staff are not providing sufficient supervision. To investigate the allegation, on 7/22/2026, LPA conducted a record review of the facility’s Personnel Report, where it was documented, the facility had various staff for the following areas: Administrative, Kitchen, Housekeeping, Direct Care Partners (DCPs), Laundry, Medication Technicians (Med-Techs), Receptionist, and Activities. Additionally, LPA’s record review of the Department’s interview with R1 on 5/07/2026, R1 revealed staff check on them often, “…every 20-30 minutes…”. During LPA’s physical plant tour on 4/14/2026, LPA observed sufficient staff to be present and assisting residents. LPA observed various staff members to be present on both floors of the residents’ living quarters assisting residents and cleaning.

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

(continue to LIC 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20260414083041

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 08/08/2026

NARRATIVE

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Regarding the allegation: Staff did not ensure the facility phone was answered. To investigate the allegation, on 6/18/2026, LPA Segovia conducted a facility visit where they conducted an interview with one (1) staff member. LPA’s interview with S1 revealed the facility has been having issues with the phone lines and internet. S1 revealed the facility had been having issues since April of 2026.

During LPA’s visit, LPA observed a technician working on the facility’s telephone lines and internet services due to technical issues. Additionally, LPA observed the facility’s continued scheduling of Spectrum for the month of June 2026, where various visitations had occurred.

Based on interviews and observations, the facility’s telephone lines were observed to be having technical issues and the facility scheduled maintenance to fix the issue. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2026

LIC9099 (FAS) - (06/04)

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