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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 08/27/2021
Date Signed: 08/27/2021 06:13:06 PM

Document Has Been Signed on 08/27/2021 06:13 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LEISURE GARDEN SENIOR ASSISTED LIVING FACILITYFACILITY NUMBER:
197610032
ADMINISTRATOR:LABELLA, MARK JFACILITY TYPE:
740
ADDRESS:44523 15TH STREET WESTTELEPHONE:
(661) 941-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 157CENSUS: 117DATE:
08/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jessica PelayaTIME COMPLETED:
05:18 PM
NARRATIVE
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LPA Spaeth conducted an visit for two complaints, #31-AS-20210806153507 and #31-AS-20210222171452. LPA interviewed ten residents and upon entering a resident's room, resident mentioned had bug bites. At 10:20 am, LPA observed bed bugs in the resident's bed. At 10:28 am LPA called Ted Bonzon (Administrator) regarding the issue. Administrator stated will have the room fumigated and a new mattress for each resident.

Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D.

Exit interview was conducted, appeal rights discussed and LPA confirmed a copy of the report will be emailed to Administrator Designee; email address is avrmanorintake@gmail.com.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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Document Has Been Signed on 08/27/2021 06:13 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/27/2021 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY
FACILITY NUMBER: 197610032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited
CCR
87303(a)

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87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary . at all times. Maintenance shall include..maintenance services & procedures for the safety and well-being of residents, ....
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During the visit, LPA observed the room was fumagated for two hours. At 4:30 pm, LPA observed the new mattresses for both beds were moved into the room, new headboard, new sheets and new comforter.
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This was not met based upon: LPA Spaeth observed bed bugs on the bed of a resident within the facility.
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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.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021


LIC809 (FAS) - (06/04)
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