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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 11/25/2024
Date Signed: 01/21/2026 09:25:50 AM

Substantiated


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
11/20/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20241120085825
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: 129DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Crystal Barrientos and Jessica PelayaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to keep passageways and stairways free of obstruction.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/21/2026 Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to correct a citation. The determination remains Substantiated. Los Angeles County Fire Department, Fire Inspector, confirmed the door in question should not lock as there can be no obstructions to paths of emergency egress. LPA met with Crystal Barrientos and explained the reason for the visit.

On 11/25/2024 at 9:45 a.m., Licensing Program Analysts (LPAs) Evelin Rios and Angelica Segovia conducted an unannounced complaint visit at this facility to investigate the above allegation. LPAs met with the Assistant Administrator Crystal Barruentos and explained the reason for the visit, entrance interview conducted. LPAs requested resident and staff roster.

At approximately 10:00 a.m. LPAs conducted a physical plant inspection of the facility. LPA’s walked up the stairway closest to the entrance and encountered a locked door to the second floor. LPA’s waved to a staff on the other side of the door and staff opened door using a keypad. (Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
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 3
Control Number 31-AS-20241120085825
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: 11/25/2024
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
 (Continued from LIC9099) On the other side of the door LPA Rios pushed at the door to attempt to open, door did not open, door is not delayed egress. From 10:05 a.m. – 12:00 p.m., LPAs interviewed the Assistant Administrator, three (3) staff, and seven (7) out of nine (9) residents, who were able to communicate. At approximately 1:30 p.m., LPAs requested copies of pertinent information which include, but not limited to LIC610E, STD850, evacuation diagram, unusual/injury incident report, and most recent fire inspection.
Allegation: Facility failed to keep passageways and stairways free of obstruction. Regarding the allegation, it is alleged that on the second floor, resident windows are bolted shut and exit doors are locked. To investigate the allegation LPAs conducted a physical plant tour which revealed one (1) out of two (2) exit doors, as per facility evacuation sketch, was locked by keypad device. LPA’s interview with the assistant administrator revealed the door is delayed egress, but later after speaking to the administrator by telephone clarified the door is not delayed egress. Assistant administrator revealed that on 11/08/2024, the facility fire inspection did not find an issue with the door being locked as it opens during an emergency. Review of unusual/injury incident report submitted to the department revealed facility self reported a resident caused a “small” fire and was sent to a hospital, no injuries reported. Interviews with seven (7) residents who responded to questioning revealed a fire had taken place in the facility with residents reporting making various observation such as, hearing fire alarms, seeing smoke, people running, the fire department utilizing a fire hose and fire extinguishers. One (1) resident revealed they saw a resident with burn injuries on face and hand. Three (3) out of the seven (7) residents who responded to questions stated they were on the second floor during the fire and evacuated using the elevator or door at the other end of the facility. Seven (7) out of seven (7) residents reveled having knowledge the door closest to the entrance is locked. LPA’s interview with staff revealed hearing about the fire or witnessing the fire take place. LPA’s tour of five (5) resident rooms found windows are not bolted shut but may be difficult to open. Interviews with all but one (1) out of the seven (7) residents that responded revealed they felt staff appropriately handled emergency protocols. LPA's met with Administrator Jessica Palaya and conducted an interview at approximately 2:34 p.m. According to administrator resident mentioned on incident report did not have injuries and there were no injuries caused by the fire. Administrator requested fire inspection from Fire Marshall. A copy will be sent to LPA when facility receives inspection documents. Based on LPAs' observation, interview and records reviewed the facility has one (1) of two (2) designated exit doors on the second floor locked with a keypad device which obstructs the door from opening. Therefore, the allegation is deemed substantiated at this time.
Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal rights provided. Copy of the report provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241120085825
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/26/2024
Section Cited
CCR
87203
1
2
3
4
5
6
7
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
POC was cleared 11/27/2024. Administrator contacted LPA to inform them the door has been disengaged by the Door Dr. a company the facility uses.
8
9
10
11
12
13
14
Based on LPAs' observation and interviews, the facility keep one (1) of (2) two exit doors on the second floor locked, which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3