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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:40:24 PM

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
12/09/2024 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20241209153418
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: 123DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jessica PelayaTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility is in disrepair
Staff do not provide a safe environment for the residents in care
Staff do not adhere to the residents' dietary needs
INVESTIGATION FINDINGS:
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At 10:50 a.m. on 12/17/24 Licensing Program Analysts (LPAs) Nicholas Reed and Angelica Segovia conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit.
To investigate the allegations above, LPAs toured the facility inside and out at 11:15 a.m. today, interviewed the administrator, staff, and 10% of residents [or thirteen (13) out of 123 residents] between 11:00 a.m. and 2:00 p.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, dietary restriction documents, and staff and client rosters at 1:30 p.m.

Regarding the allegation "Facility is in disrepair" it was alleged that facility elevators continuously break down, staff and residents get stuck inside. Facility tour revealed that both elevators were operational today. LPAs did not get stuck in either elevator. Interviews with twelve (12) out of thirteen (13) residents and four (04) out of four (04) staff interviewed today confirmed that they have not been trapped inside of facility elevators and they are operational. Interview with Resident #1 (R1) at 11:45 a.m. today revealed the
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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-20241209153418
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: 12/17/2024
NARRATIVE
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back elevator is slow, but the front elevator works fine. Interview with Resident #2 (R2) at 12:45 p.m. today revealed they were not able to get out of the back elevator a few weeks ago, so they had to use the front elevator. Interview with the administrator at 11:00 a.m. today revealed that necessary maintenance was recently performed by an outside vendor on the back elevator. The administrator has not received any reports of people being trapped inside elevators. Record review of a work order revealed that an outside vendor completed mechanical and safety maintenance on 11/26/24. Based on observations, interviews, and record review, the facility elevators are in good repair today. The facility has performed maintenance in a timely manner as well. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.
Regarding the allegation "Staff do not provide a safe environment for the residents in care” it was alleged that most resident bedroom windows do not have screens, and a stranger entered a resident bedroom causing the resident to feel unsafe. Interview with the administrator revealed they received no reports of residents feeling unsafe or strangers entering through resident windows. Facility tour revealed that all resident bedroom windows had screens attached and were in good repair. Interviews with thirteen (13) out of thirteen (13) residents and three (03) out of three (03) staff revealed they feel safe in the facility and no strangers have entered through their windows. Based on observations and interviews, the facility staff are providing a safe environment for residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.
Regarding the allegation "Staff do not adhere to the residents' dietary needs " it was alleged that some residents are unable to eat facility food due to staff not providing a menu which suits their needs. During facility tour, LPAs observed special dietary restriction lists posted in the kitchen around 11:15 a.m. Postings included residents with allergies, pureed diets, chopped diets, low salt diets, and diabetic diets. Also posted were the main and alternate menus for today and the week. Interview with the administrator revealed that current and new resident dietary needs are reviewed, and the dietary restriction documents are updated accordingly. Interview with the kitchen director at 11:25 a.m. today revealed that staff accommodate residents’ dietary needs through preparing modified meals and alternate menus. If residents request different meals or second portions, kitchen staff willingly accommodate their requests. LPAs also saw adequate supplies of perishable and non-perishable foods stored in the refrigerators, freezers, and pantries. Interviews with three (03) out of three (03) residents with dietary restrictions between 12:20 p.m. and 12:35 p.m. today revealed they were served meals according to their modified diets. Interviews with ten (10) our of ten (10) other residents revealed they are able to eat the food served. Based on observations, interviews, and record review, the facility staff are adhering to residents’ dietary needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2