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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610032
Report Date: 11/25/2024
Date Signed: 11/25/2024 03:02:24 PM

Document Has Been Signed on 11/25/2024 03:02 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
N LA & CEN COA AC/SC, 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: 129DATE:
11/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jessica PelayaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Evelin Rios and Angelica Segovia conducted an unannounced case management - deficiencies visit in conjunction to Complaint #31-AS-20241120085825. LPA's met with the Administrator, Jessica Pelaya and Assistant Administrator Crystal Barruentos and explained the reason for the visit, entrance interview conducted.

During the complaint investigation it was revealed the facility self reported to Community Care Licensing (CCL) on 10/25/2024, that a resident had started "small fire" in their room on 10/20/2024, five days after the fire had occurred. According to interviews with the assistant administrator and seven (7) residents, the fire, which occurred in the facility, required 911/ Fire Department response. The facility failed to report the fire to CCL the next working day.

Deficiency cited, refer to LIC809-D. Appeal rights provided. Copy report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/25/2024 03:02 PM - It Cannot Be Edited


Created By: Evelin Rios On 11/25/2024 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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)
Type B
12/30/2024
Section Cited
CCR
87211(a)(3)

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(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (3) Fires... which occur in... the premises shall be reported no later than the next working day to the licensing agency. This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding on the allegation cited by POC due date 12/02/2024.
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According to record reviews the facility failed to report a facility fire to CCL the next working day which poses an potential health, safety, or personal rights risk to persons 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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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