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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604160
Report Date: 05/04/2022
Date Signed: 05/04/2022 02:10:54 PM

Document Has Been Signed on 05/04/2022 02:10 PM - It Cannot Be Edited

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. #250
WOODLAND HILLS, CA 91364
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:
05/04/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ross Hashemi, Pam Hashemi, Michelle MaurerTIME COMPLETED:
02:00 PM
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An Informal Conference was conducted today in the Woodland Hills North Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss deficiencies cited in complaint control #29-AS-20210604095550 and complaint control #31-AS-20200316103126.

Present at today's meeting included licensee representatives Ross Hashemi Pam Hashemi, and Michelle Maurer, Licensing Program Manager (LPM) Jeralyn Pfannenstiel and Licensing Program Analyst (LPA) Ashley Smith.

The informal conference process was explained to the licenses. The licenses was also informed that this Informal Conference is a part of the administrative action process and that further citations may result in a Non-Compliance Conference, which could lead to a referral for Administrative Review by the Department.

Brief History: The facility was first licensed in 11/15/2002, for a capacity of six residents.

LPM Pfannenstiel discussed deficiencies cited during the complaint investigation, which included failure to assist residents with the self-administration of medication as prescribed, failure to follow the hospice care plan as described; failure to ensure that the facility was kept in good repair; and, failure to issue a legal eviction. At this time, the licensee has cleared the Plan of Corrections in a timely manner. All parties discussed the complaint investigation and potential ramifications of the complaint findings. The licensee communicated their due diligence in maintaining voluntary compliance with applicable licensing regulations.

Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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