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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:43:26 PM

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
03/05/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250305155629
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: 119DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica Pelaya / AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility failed to conduct a proper pre-admission appraisal.

INVESTIGATION FINDINGS:
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On 3/12/25 at approximately 9:30 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced initial visit to the facility. LPA signed in and was greeted by Administrator Jessica Pelaya. LPA stated the reason for the visit. An entrance interview was conducted with the administrator.

Allegation: Facility failed to provide care for resident with restricted health condition. It was alleged the facility is not providing proper catheter care. To investigate the allegation LPA requested resident #1's (R1's) record, a resident roster and staff roster. From 9:50 a.m. to 10:50 a.m., LPA interviewed R1. At 11:17 a.m., LPA interviewed a placement consultant used by the facility via telephone. From 11:40 a.m. to 12:40 p.m., LPA reviewed R1's record and obtained copies which include Preplacement Appraisal Information (LIC603), Physician's Report (LIC602A), Appraisal/Needs and Services Plan (LIC625), Unusual Incident Reports, and R1's records from the Skilled Nursing Facility (SNF), R1 was in prior to admittance to this facility. At approximately 1:23 p.m., LPA conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. (Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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 5
Control Number 31-AS-20250305155629
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: 03/12/2025
NARRATIVE
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(continued from LIC9099) Allegation #1: Facility failed to conduct a proper pre-admission appraisal. It was alleged the facility admitted Resident #1 (R1) without knowledge of R1's restricted health condition. LPA's interview with R1 confirmed the use of a catheter. R1 informed LPA facility staff claims they first saw the catheter when R1 was brought into the facility on a gurney. R1 states they were not aware the facility did not know about the catheter as a representative from the facility had visited them in person prior to admittance. LPA's interview with the administrator revealed they did not know about the catheter and had received R1's skilled nursing record the same day the resident was admitted to the facility. According to the administrator they would not have accepted R1 had they known R1 had a catheter. Furthermore, according to the administrator the consultant used for placement assistance had not mentioned the presence of a catheter. According to the administrator they admitted R1 based on the information gathered from the consultant. Interview with the consultant corroborates they visited R1 on behalf of the facility and did not see the catheter bag. The consultant informed LPA they conducted an interview with R1. LPA's review of SNF paperwork confirms R1's use of catheter. LPA's review of the Preplacement Appraisal Information (LIC603) is dated the same date R1 was admitted to the facility. On the LIC603 Services Needed for Toileting, including assistance equipment, or assistance of another person is checked "Yes" with no explanation as to what kind of assistance R1 will need. LPA's review of hospital discharge paperwork after admittance to the facility confirmed resident has been released back to facility without Home Health services on different occasions. According to the administrator, the facility has created a plan to find a suitable facility for R1. Since R1 now qualifies for assistance, the facility is able to assess R1 and place an order for Home Health until a suitable facility is found.

Based on record review and interviews, although the facility claims they did not know about the catheter, the consultant used represented the facility when they visited the resident in person. Either the consultant did not conduct a proper functional capabilities evaluation, or the facility did not interview R1 and failed to complete the preplacement appraisal prior to admission. Therefore, this allegation is deemed SUBSTANTIATED at this time.



Exit interview conducted. Deficiency cited (refer to LIC9099-D). Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
03/05/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250305155629

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: 119DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica Pelaya / AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility failed to provide care for resident with restricted health condition.
INVESTIGATION FINDINGS:
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13
On 3/12/25 at approximately 9:30 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced initial visit to the facility. LPA signed in and was greeted by Administrator Jessica Pelaya. LPA stated the reason for the visit. An entrance interview was conducted with the administrator.

Allegation: Facility failed to provide care for resident with restricted health condition. It was alleged the facility is not providing proper catheter care. To investigate the allegation LPA requested resident #1's (R1's) record, a resident roster and staff roster. From 9:50 a.m. to 10:50 a.m., LPA interviewed R1. At 11:17 a.m., LPA interviewed a placement consultant used by the facility via telephone. From 11:40 a.m. to 12:40 p.m., LPA reviewed R1's record and obtained copies which include Preplacement Appraisal Information (LIC603), Physician's Report (LIC602A), Appraisal/Needs and Services Plan (LIC625), Unusual Incident Reports, and R1's records from the skilled nursing facility R1 was in prior to admittance to this facility. At approximately 1:23 p.m., LPA conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. (Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20250305155629
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: 03/12/2025
NARRATIVE
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(Continued from LIC9099-A) LPA's interview with R1 confirmed the use of a catheter. R1 informed LPA facility staff claims they first saw the catheter when they were brought into the facility on a gurney. R1 states they were not aware the facility did not know about the catheter as a representative from the facility had visited them in person prior to admittance. LPA's interview with the administrator revealed they did not know about the catheter and had received R1's skilled nursing record the same day the resident was admitted to the facility. According to the administrator they would not have accepted R1 had they known R1 had a catheter. Furthermore, they contacted the Skilled Nursing Facility and attempted to return the resident but could not. According to the administrator the consultant used for placement assistance and the skilled nursing facility had not mentioned the presence of a catheter. According to R1 and the administrator the facility staff do not assist with the catheter because staff at the facility are not appropriately skilled professionals or have been trained by one to assist R1 with their catheter. According to R1 they would prefer to be transferred to a skilled nursing facility. According to the administrator they immediately call 911 to have R1 transported to the hospital when catheter needs arise. R1 confirmed that due to mitigating circumstances, they did not qualify for Home Health services upon release to the facility on one occasion, and the facility staff are not able to provide assistance with restricted health conditions. LPA's review of hospital discharge paperwork after admittance to the facility confirmed resident was released back to facility without Home Health services. According to the administrator, the facility has created a plan to find a suitable facility for R1. Since R1 now qualifies for assistance, the facility is able to assess R1 and place an order for Home Health.

Based on record review and interviews although the facility failed to observe R1's use of a catheter prior to admitting them to the facility they have sought medical attention to address R1's catheter needs until a suitable facility is found. Therefore this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250305155629
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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2025
Section Cited
CCR
87457(c)(1)(A)
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87457 Pre-Admission Appraisal (c)Prior to admission... (1)The appraisal shall document, at a minimum:(A) An evaluation of the prospective resident's functional capabilities,... as specified in Sections 87459, Functional Capabilities... This requirement is not met as evidenced by:
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The Administrator has agreed to the following: 1. Since R1 is still in the facility a Re appraisal and Appraisal needs and services will be conducted.
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Based on interviews and resident records review the licensee failed to conduct a proper preplacement evaluation with R1 to make sure the facility was suitable for R1 which is an immediate health and safety risk to resident in care.
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2. Staff responsible of placement/intake will take "Pre-admissions appraisal" in-service training and Submit training schedule, training material and sign in sheet to LPA by POC due date.
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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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5