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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 09/25/2024
Date Signed: 09/25/2024 05:11:47 PM

Substantiated


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
08/29/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240829144644
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:
09/25/2024
UNANNOUNCEDTIME BEGAN:
03:21 PM
MET WITH:Jessica PelayaTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not ensure resident was taken to his medical appointments
INVESTIGATION FINDINGS:
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On 9/25/2024 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 and LPA explained the purpose of this visit was to deliver the findings.

The investigation consisted of the following: On 09/04/2024, LPA conducted an initial complaint investigation. LPA Spaeth reviewed residents' records at 12:45 pm until 1:15 pm. LPA requested the resident roster and copies of the residents' records. LPA Spaeth received the documents requested. At 1:30 pm until 2:30 pm, LPA Spaeth interviewed ten (10) residents, twelve (12) staff members and the Administrator.

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

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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 4
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
08/29/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240829144644

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: DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
03:21 PM
MET WITH:Jessica PelayaTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify resident's authorized representative of incident
Staff are not meeting resident's needs
INVESTIGATION FINDINGS:
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12
13
Regarding the allegation, Staff did not notify resident's authorized representative of the incident: it is being alleged the Licensee did not notify the resident’s responsible parties that R1 was hospitalized. LPA spoke to R1’s responsible party on 9/03/2024 at 10:00 am who stated the Administrator informed them that R1 had been hospitalized. The Administrator stated due to the severity of R1’s condition, the safety of R1 and other residents, the facility staff immediately called 911. Based upon the interview of the responsible party and the Administrator, the allegation is unsubstantiated.

Regarding the allegation, Staff are not meeting resident's needs: it is being alleged staff are not cleaning residents’ rooms and the residents must clean their own room. LPA Spaeth interviewed ten (10) out of one hundred twenty-nine (129) residents who stated staff clean their rooms each day. LPA interviewed twelve (12) out of forty-six (46) staff members who unanimously confirmed residents’ rooms are cleaned each day by staff. Therefore, the allegation is unsubstantiated.
Exit interview conducted, and a copy of the report was given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20240829144644
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: 09/25/2024
NARRATIVE
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Regarding the allegation, Staff did not ensure resident was taken to his medical appointments: it is being alleged that facility staff have been neglecting the client’s mental health treatment by not ensuring R1 attends the appointments. LPA’s interview of the Administrator revealed R1 missed the June, 2024 appointment because the facility driver was not available. The Administrator stated the facility driver is the only person who can drive residents to their appointments. R1 confirmed they missed the appointment. Based upon interviews conducted, the allegation is substantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20240829144644
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2024
Section Cited
CCR
87464(f)(6)
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87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation as specified in Section 87465… This requirement is evidenced by:
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LPA Spaeth discussed with the Administrator the facility program states the facility will provide transportation services per the program design.
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The facility staff did not provide R1 transportation to their doctor's appointment 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4