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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 07/28/2022
Date Signed: 07/29/2022 08:24:50 AM

Document Has Been Signed on 07/29/2022 08:24 AM - 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: 110DATE:
07/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jessica Pelaya TIME COMPLETED:
11:30 AM
NARRATIVE
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LPA conducted an unannounced visit regarding Complaint 31-AS-20200731134509 and completed a tour of the facility. At 11:30 am, LPA entered the dining hall and observed three caregivers were not wearing a mask. Upon walking into the hallway on the first floor, LPA observed two staff members were not wearing a mask.

Based upon LPA's observations, the allegation is substantiated. 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/29/2022 08:24 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 07/28/2022 at 12:49 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: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2022
Section Cited
CCR
87470(b)(2)

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87470(b)(2)-Infection control requirements - 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 remind staff and will place signs throughout the facility as a reminder to wear masks
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Upon touring the facility, LPA observed five staff members were not wearing a mask which poses an immediate health and safety risk to residents in care.
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Type B
07/28/2022
Section Cited
CCR87761(d)

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When a facility is cited for a deficiency and violates the same regulation subsection within a 12-month period, the facility shall be cited and an immediate penalty of $250 per cited violation shall be assessed for one day only. Thereafter a penalty of $50 per day, per cited violation, shall be assessed until the deficiency is corrected.
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Administrator will ensure staff are reminded to wear masks for entire shift.
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Immediate Civil Penalty of $250.00 was assessed on 8/20/2015.
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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: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


LIC809 (FAS) - (06/04)
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