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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 06/06/2022
Date Signed: 06/06/2022 06:29:22 PM

Document Has Been Signed on 06/06/2022 06:29 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:JESSICA PELAYAFACILITY TYPE:
740
ADDRESS:44523 15TH STREET WESTTELEPHONE:
(661) 941-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 157CENSUS: 113DATE:
06/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Jon DipalingTIME COMPLETED:
06:00 PM
NARRATIVE
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During LPA's unannounced visit regarding an incident report received by LPA Spaeth, LPA Spaeth and Administrator Jon Dipaling took a tour of the facility from 4:05 pm until 4:20 pm, LPA observed four staff members were not wearing masks. LPA verbally confirmed with Administrator that all staff are required to wear masks when working at the facility.

Based upon LPA's observations, , a deficiency is hereby issued. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/07/2022 02:00 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/07/2022 01:57 PM


Created By: Melissa Spaeth On 06/06/2022 at 05:05 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
CCLD Regional Office, 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: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2022
Section Cited
CCR
87470(b)(2)

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All staff and volunteers providing direct care to a resident....shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents...This requirement was not met as evidenced by:
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Administrator will conduct a training reminding staff of the need to wear masks and also review proper donniing and doffing of all PPE. Administrator will provide sign in sheet with staff member's signature after training has been conducted.
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Upon touring the facility, LPA observed four staff members were not wearing a mask which poses an immediate 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.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
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


LIC809 (FAS) - (06/04)
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