197610032-1-15-2025-31-AS-TAGD-DE4MLF-20250221084216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 01/15/2025
Date Signed: 01/15/2025 03:40:00 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.RO, 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
01/08/2025 and conducted by Evaluator Angelica Segovia

COMPLAINT CONTROL NUMBER: 31-AS-20250108133702

FACILITY NAME:	LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY		FACILITY NUMBER:	197610032
ADMINISTRATOR:	JESSICA PELAYA		FACILITY TYPE:	740
ADDRESS:	44523 15TH STREET WEST		TELEPHONE:	(661) 941-4578
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	157	CENSUS: 122	DATE:	01/15/2025
		UNANNOUNCED	TIME BEGAN:	12:17 PM
MET WITH:	Jessica Pelaya -Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not provide adequate care or supervision resulting in resident being stuck in the toilet for an extended period of time

INVESTIGATION FINDINGS:

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On 1/15/25 at approximately 11:00 AM, Licensing Program Analysts (LPAs) Angelica Segovia and Gary Tan conducted an unannounced initial visit to the facility. LPAs were greeted by Administrator Jessica Pelaya. LPAs stated the reason for their visit.
It was alleged that Resident (R1) was found stuck inside of a toilet for four (4) hours resulting in R1 being admitted to the hospital for medical care.
To investigate the allegation LPAs asked for census, staff, and resident Rosters. LPAs conducted a physical plant tour at approximately 12:30 PM. LPAs requested pertinent documents at approximately 1:00 PM. LPAs conducted interviews between 1:15 PM to 2:30 PM. LPAs interviewed one (1) resident and five (5) staff members. LPAs interview with Resident #2 (R2) confirmed that Resident #1 (R1) takes one (1) to one and half (1 ½) hours in the bathroom whenever R1 uses the bathroom and always locked the door. Interviews with staff members confirmed that five (5) out of five (5) stated that R1 independently uses the bathroom by themselves. Five (5) out of five (5) staff members also confirmed that R1 takes a long time using the restroom and always lock the door.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250108133702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY	FACILITY NUMBER: 197610032
	VISIT DATE: 01/15/2025

NARRATIVE

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LPAs Interview with Staff member one (S1) at 1:30 PM, revealed that when the incident occurred, they were conducting their morning Medication pass routine at around 8:00 AM and went to R1’s room but R1 was in the bathroom. S1 came back to check on R1 to give R1’s medication after twenty (20) minutes later and R1 was still in the bathroom. On the third attempt of S1 at around 8:50 AM, S1 found out that R1 was still and the bathroom but this time, S1 became worried and called Maintenance at around 9:00 AM to help gain access into the bathroom since R1 was not responding to them. After maintenance gained access inside the bathroom it became apparent R1 was stuck and was not able to get up by themselves. After several failed attempts to get R1 separated from the toilet, emergency services were called. At around 10:00 AM emergency services arrived and could not get R1 separated from the toilet. At around 11:30 AM R1 was transported with the toilet to the hospital where R1 was admitted and treated. Further interview with (R2) confirmed that R1 uses the bathroom by themselves and did not request any kind of assistance during the incident.

Based on record review and interviews this allegation is UNSUBSTANTIATED at this time. No other health and safety issues observed. Exit interview conducted and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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