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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610032
Report Date: 09/05/2025
Date Signed: 09/05/2025 02:03:51 PM

Substantiated


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
07/15/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240715094017
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: 124DATE:
09/05/2025
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Crystal BarrientosTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Residents are not able to leave the building due to staff locking the doors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility, met with administrator, Crystal Barrientos, and explained the reason for the visit.

---Residents are not able to leave the building due to staff locking the doors.

It was alleged that residents are locked in inappropriately. To investigate the allegation, on 07/18/2024 LPA Melissa Spaeth interviewed six (06) residents and four (04) staff. On 09/05/2025 LPA Duguma conducted a physical plant tour of the facility, interviewed one (01) additional staff and eight (08) additional residents. During interviews with residents, six (06) out of fourteen (14) stated they are able to leave the facility without having someone from the other side of the door open it for them. All other residents stated they and other residents, exit throught the locked doors marked "OFFICE" to enter and exit the facility.
(CONT. LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
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 3
Control Number 31-AS-20240715094017
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: 09/05/2025
NARRATIVE
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During the interviews with staff, all staff stated yes, the door is locked, however, there is someone in the office to let residents out twenty-four (24) hours a day, seven (07) days a week. Staff added there are alternate doors for residents to use in the event of an emergency. Upon arrival today, LPA Duguma observed two (02) residents in front of the building. As LPA was about to approach what appeared to be the main entrance to the facility, the two (02) residents gestured towards the office entrance and stated, "you have to go in and out through there". During the tour LPA observed the exit door all residents are using to enter and exit the building is equipped with a digital locking mechanism and marked OFFICE. LPA did note other exits in the facility that are delayed egress with alarms but not used as main entrances and exits which could pose a potential health, safety and personal rights risk to residents in care should they rely on muscle memory in the event of an emergency such as a smoke filled section of the building. After bring this to the Administrator's attention, facility immediately removed the digital locking mechanism from the OFFICE door and began using the double doors at the front of the building for residents to enter and exit the facility.

Based on interviews and observations, there is enough information to verify the allegation, therefore the allegation is SUBSTANTIATED at this time.

A plan of correction was not issued at this time as the facility took corrective measures in the presence of the LPA.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240715094017
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
87468.1(a)(6)
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87468.1 (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by; Based on
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A plan of correction was not issued at this time as the facility took corrective measures in the presence of LPA.
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observations and interviews, the licensee is using the office as entrance and exit for residents and door has locking mechanism for residents trying to EXIT the building which poses a potential health, safety and personal rights risk to residents 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3