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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 04/24/2024
Date Signed: 04/24/2024 03:46:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20240417143123
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: 130DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Jessica Pelaya- AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not respond to communications from resident's representative in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with administrator Jessica Pelaya and explained the reason for the visit. During the course of the investigation, interviews and record review were made. At 12:10 PM, LPA requested resident and staff roster. At 12:20 PM, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 12:40 PM, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 12:45 PM – 1:45 pm, LPA interviewed the Administrator, two (2) staff and thirteen (13) residents out of 130.
Allegation: Staff did not respond to communications from resident's representative in a timely manner.
It was alleged that R1's representative had made multiple attempts to communicate with facility staff regarding changing primary payee from R1's representative to the facility. LPA interviewed Administrator regarding the allegation. (Continue on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
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 31-AS-20240417143123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY
FACILITY NUMBER: 197610032
VISIT DATE: 04/24/2024
NARRATIVE
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Administrator wasn't aware of the issue since this matter is related to bustiness Administration. Administrator confirmed that R1's representative had never brought communications concerns to them.
Interview with S2 and S3 revealed that R1's representative called twice and both times all concerns were solved. S3 stated that the first time R1 representative called was about the possibility of making the facility as primary payee and the second time R1's representative requested to know the procedure for the change of the payee.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted a copy of this report delivered.


SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2