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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604160
Report Date: 06/07/2022
Date Signed: 06/07/2022 10:04:28 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
06/06/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220606165124
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: 4DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Pam HashemiTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Staff are not following masking protocols to prevent the spread of COVID-19
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 physical plant tour at 8:30 a.m., and interviewed staff at 8:35 a.m., 9:05 a.m., 9:10 a.m., and 9:17 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, the three staff on site, including Staff #1 (S1) were wearing masks. Yet information obtained from a credible witness confirmed on 5/10/2022, a credible witness noted that S1 and other staff were not wearing masks while in close proximity of residents. Per conversations with staff, the licensees are conducting an in-service for all the facilities under the licensee's jurisdiction. Based on the investigation, there is sufficient evidence to support the claim that staff were not following masking protocols to prevent the spread of COVID-19. 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: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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-20220606165124
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: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/09/2022
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 6/9/2022.
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This requirement was not met as evidenced by:
Based on observations from a credible witness, 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: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
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