<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 08/14/2024
Date Signed: 08/15/2024 07:45:17 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
07/23/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240723153041
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: 133DATE:
08/14/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jessica PelayaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not releasing resident’s medical records despite receiving a medical release form
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/14/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to deliver the findings for this complaint.

The investigation consisted of the following: On 08/01/2024 Licensing Program Analyst (LPA) Melissa Spaeth and Licensing Program Manager (LPM), Troy Agard initiated a complaint investigation. LPA Spaeth and LPM Agard toured the facility at 10:00 am until 10:30 am. LPA reviewed resident records and obtained copies of documentation. LPA and LPM also interviewed a resident (R1) at 11:00 am until 11:30 am.

Conintued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
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-20240723153041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY
FACILITY NUMBER: 197610032
VISIT DATE: 08/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation revealed the following: Regarding the allegation: Staff are not releasing resident’s medical records despite receiving a medical release form. It’s being alleged that a resident (R1) had stated to the reporting party they granted permission for a friend to receive copies of their records. It is also alleged that R1 signed a Release of Client/Resident Medical Information Form (LIC 605A) on 12/03/2023 in which they authorized a friend to receive all their medical records from the facility.

On 06/11/2024, a similar allegation was investigated in complaint number 31-AS-20240301092942 in which it was alleged the facility refused to provide medical information despite having signed consent. On 07/23/2024 the regional office received additional information from a new complaint.

On 8/01/2024, LPA Spaeth and LPM Agard interviewed R1 at 11:00 am until 11:30 am who stated all their medical records could be released and confirmed who the medical records could be released to. During an interview with the facility administrator, they were aware of the consent but when confirmed with R1, R1 did not provide the same response and was unable to get confirmation from the resident. The department shared with the facility R1’s current request to have their records released as of the day of the interview. The facility administrator was made aware of this confirmation on the day of the interview.

Based on interviews conducted and records reviewed the allegation(s) is unsubstantiated.

An exit interview was conducted, and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2