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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603437
Report Date: 06/06/2022
Date Signed: 06/06/2022 09:55:41 AM

Substantiated


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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220603135530
FACILITY NAME:LEISURE LIVING INC.FACILITY NUMBER:
197603437
ADMINISTRATOR:PARVIN HASHEMIFACILITY TYPE:
740
ADDRESS:30821 CATARINA DR.TELEPHONE:
(818) 879-9988
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 4DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Michelle MaurerTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff are not wearing PPE
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial 10-day visit. The LPA met with staff and explained the reason for the visit. To investigate, the LPA conducted a tour at 9:10 a.m., interviewed residents at 9:30 a.m. and 9:33 a.m., and interviewed staff at 9:45 a.m.

It was alleged that staff in the facility were not wearing masks while in close contact with the residents. Upon arrival to the facility at 9:10 a.m., the two staff on site (Staff #1, Staff #2) were observed not wearing masks. The LPA observed that at approximately 9:30 a.m., S1 and S2 were wearing masks. Yet information obtained from a credible witness confirmed on 5/10/2022 and 9/21/2021, the credible witness noted that S1 and S2 were observed not wearing masks while in close proximity of residents. Based on the investigation, there is sufficient evidence to support the claim that staff were not wearing the required personal protection equipment (PPE). This allegation is deemed Substantiated at this time.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
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 2
Control Number 29-AS-20220603135530
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE LIVING INC.
FACILITY NUMBER: 197603437
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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The Administrator agreed to do the following:
Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 6/8/2022.
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This requirement was not met as evidenced by:
Based on observations and interview, the licensee did not comply with the section cited above, as staff were not wearing face masks in the facility, which poses an immediate personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
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