197610032-4-2-2025-31-AS-TAGD-DFTV8P-20250417161305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 04/02/2025
Date Signed: 04/02/2025 11:27:53 AM

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
03/11/2025 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20250311111319

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: 117	DATE:	04/02/2025
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	09:51 AM

ALLEGATION(S):

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Staff did not provide resident with an appraisal
Staff did not provide responsible party with an admissions agreement
Staff do not communicate with responsible party regarding resident's care
Staff did not assist resident with obtaining medical care

INVESTIGATION FINDINGS:

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On 4/02/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to present the findings.

The investigation consisted of the following: On 3/12/2025, Licensing Program Analyst (LPA) Melissa Spaeth conducted an initial complaint investigation. LPA Spaeth reviewed the residents' files, interviewed eight (8) out of twenty-eight (28) staff members and interviewed twelve (12) out of one hundred seventeen (117) residents. LPA received copies of resident's records, resident roster, and the staff roster.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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-20250311111319

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: 04/02/2025

NARRATIVE

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Regarding the allegation, staff did not provide resident with an appraisal: It is being alleged a resident did not receive a facility appraisal prior to their admission into the facility. On 3/12/2025, LPA reviewed the resident’s file (R1) and observed the Preplacement Appraisal Information (LIC 603) was completed prior to R1’s admission to the facility.

Regarding the allegation, Staff did not provide responsible party with an admissions agreement: it is being alleged a resident’s responsible party was not aware R1 was admitted to the facility and the responsible party did not sign the admissions agreement. LPA reviewed R1’s documentation and did not observe a Power of Attorney (POA). R1 was interviewed on 3/12/2025 at 12:00 pm and stated there is no Power of Attorney. R1 stated they are able to make their own decisions.

Regarding the allegation, Staff do not communicate with responsible party regarding resident's care: It is being alleged the Administrator has not communicated with the responsible party regarding the hospice care and facility care of R1. The Administrator was interviewed on 3/12/2025 at 10:00 am and stated since there is not a POA for R1, the care of the resident must be kept confidential. LPA Spaeth reviewed R1’s files and did not observe hospice paperwork. R1 and the Administrator both confirmed R1 was not receiving hospice care.

Regarding the allegation, Staff did not assist resident with obtaining medical care: It is being alleged R1 missed a medical appointment because staff did not arrange R1’s transportation. R1 stated they did not want to go to the appointment and preferred the appointment to be arranged at another time. The Administrator confirmed R1 informed them to cancel the appointment. R2-R12 unanimously stated staff arrange transportation for all their medical appointments.

Based upon LPA’s review of the resident’s records and the interviews conducted, the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC9099 (FAS) - (06/04)

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