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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604160
Report Date: 06/11/2021
Date Signed: 06/11/2021 02:04:44 PM

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
06/04/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210604095550
FACILITY NAME:LEISURE LIVING INC.FACILITY NUMBER:
197604160
ADMINISTRATOR:PAM HASHEMIFACILITY TYPE:
740
ADDRESS:30822 JANLOR DR.TELEPHONE:
(818) 879-9944
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 5DATE:
06/11/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Pam Hashemi and Michelle MaurerTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility has bedbugs.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith conducted an initial complaint inspection. The LPA met with Administrators Michelle Maurer and Pam Hashemi and explained the reason for the visit.

During today’s visit, the LPA conducted a tour at 12:03pm, reviewed and obtained records at 12:17pm, conducted interviews at 12:29pm, 12:39pm, and 1:12pm; and, reviewed the medication closet along with staff at 12:56pm.

Regarding the allegation: Facility has bedbugs
It was alleged that the facility had bedbugs. Interviews and records review revealed that this facility self-reported this incident via phone to the Department on 5/28/2021 in regard to the discovery of bed bugs. The facility submitted an Incident Report on 6/2/2021.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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 29-AS-20210604095550
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: 197604160
VISIT DATE: 06/11/2021
NARRATIVE
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 The incident report describes that the presence of bed bugs was identified on 5/18/2021, an inspection was conducted on 5/20/2021, and a fumigation of the facility took place on 6/2/2021. During that time, the residents and staff were temporarily relocated to a hotel.

Based on the investigation, there is sufficient evidence to support the claim that the facility had bedbugs. This allegation is deemed Substantiated at this time.


Regarding the allegation: Facility is in disrepair.

It was alleged that there were items in the facility that required repair, specifically in the medication closet. The LPA conducted a physical plant tour at 12:03pm and identified no immediate concerns. During today’s visit at 12:59pm, the LPA and staff observed the medication cabinet. The LPA observed the lights in the medicine closet, and identified that there were three battery operated lights – one on the wall, a flashlight, and a handheld light. Whereas a flashlight was working, the other lights in the cabinet were not operable at the time of observation.

Based on the investigation, there is sufficient evidence to support the claim that the facility is in disrepair. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided, along with appeal rights.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20210604095550
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: 197604160
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2021
Section Cited
CCR
87303(a)
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87303(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Plan of Correction met regarding the bed bug issue. LPA has a copy of the invoice of the treatment.
2. Change the batteries in the lights; submit proof to LPA by 6/14/2021.
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Based on interview, records review, and observation, the licensee did not comply with the section cited above, as the facility recently had bed bugs and some lights were observed to be inoperable, which poses a potential health and safety 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: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC9099 (FAS) - (06/04)
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