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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 11/02/2024
Date Signed: 11/02/2024 03:55:56 PM

Document Has Been Signed on 11/02/2024 03:55 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LEISURE GARDEN SENIOR ASSISTED LIVING FACILITYFACILITY NUMBER:
197610032
ADMINISTRATOR/
DIRECTOR:		JESSICA PELAYAFACILITY TYPE:
740
ADDRESS:44523 15TH STREET WESTTELEPHONE:
(661) 941-4578
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 157CENSUS: 122DATE:
11/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Jessica Pelaya - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an Annual Required visit and inspection of the facility. LPA met with the administrator Jessica Pelaya and explained the reason for the visit.

At approximately 09:43 AM, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. Currently there are eighteen (18) residents receiving hospice care and sixty eight (68) residents on the Assisted Living Waiver (ALW). The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. The smoke detectors were last serviced on 09/12/24. Facility also have a functional sprinkler system. There are fire extinguishers located throughout the facility hallways. Fire extinguishers were last inspected on 11/30/23. The Fire Inspection was last held on 09/17/24.

Kitchen: The kitchen has an industrial setting and observed to be clean and in proper order. Appliances and fixtures were observed to be functional. Sufficient amount of perishable and non-perishable food were in stock and properly stored. Kitchen is inaccessible to residents. Dishwashing liquids and other cleaning agents are separated from food preparation area.

Bedrooms: The facility has two (2) floors. The first floor has fifty-two (52) shared bedrooms and the second floor has sixty-four (64) shared bedrooms. Random rooms were inspected and LPAs observed appropriate beddings and linens with sufficient lighting.

Bathrooms: Each resident unit on both floors have their own bathrooms. Both bathrooms were properly supplied and had functional fixtures including grab bars. Hot water temperature was measured at a range of 105.4°F to 109.4°F. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/02/2024
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Common Areas: These includes the activity room, TV rooms, beauty shop and dining area. The common areas were properly furnished. The furniture were in good repair. Hallways and passageways are free of obstruction. The front door has a delayed egress. Per STD 850, fire clearance for delayed egress and secured locked perimeter was approved on 07/30/20.

Surrounding Grounds: Entry/exits and hallways on the first and second floor were free of obstruction. Toxins and cleaning supplies stored and inaccessible during inspection. There is patio furniture appropriate for outdoor use. The outdoor area was free of hazards.

Laundry Room and Shower room: There is a laundry room located on both the first and second floors. Laundry room is kept locked at all times. There is also a Common Shower room on each floor for residents who needed assistance in showering. Shower rooms were observed to be clean and in proper order.

Resident Files: Resident files are maintained in the administrator's office. LPA conducted a file review of random resident records to ensure compliance of licensing forms. Residents file were observed to be current and updated.

Staff Files: Staff files are maintained at the business office. LPA also conducted a file review of staff records and observed to be current and updated.

Medications: Medication Room is located near the administrator's office. Medication room is locked at all times. Medication and Medication Records were review for proper documentation.

Office/Work Station: The administrator's office is located near the front entrance, near check-in, and the business office is located at the right corner, front side of the building. Staff records and two computers, for staff use were maintained in the business office. Fire drill was last conducted on 10/07/24.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC809 (FAS) - (06/04)
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