Leisure Living Inc.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:40AM. LPA met with staff upon arrival and Administrator Michelle Maurer at 02:38PM. Entrance interview conducted. Beginning at 11:50AM, the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: LPA inspected the kitchen at 11:50AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Sharp objects and cleaning supplies were stored in locked and inaccessible cabinets. BEDROOMS: There are seven (7) bedrooms of which six (6) are private resident rooms and one (1) is a staff room. Staff room was observed to be locked. Five (5) rooms have exits to the exterior. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. LPA observed the exit in Bedroom #5 obstructed with resident belongings. Staff cleared the exit during the visit. RESTROOMS: There are three (3) restrooms, two (2) are attached to resident rooms and one (1) is in the hallway for resident, staff, and visitor use. LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in all three (3) bathrooms and were between 105.1 F-105.3 degrees F, which is within the required range. Report Continued on LIC 809-C. COMMON SPACES: At the time of the visit, living room and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. LPA observed surveillance cameras in common spaces with disabled audio components. Fire extinguisher was fully charged and last purchased 08/14/2025. All hardwired smoke and carbon monoxide detectors were tested at 12:14PM and all were functional at the time of the visit. GARAGE/LAUNDRY/GROUNDS: LPA observed the garage to be locked and inaccessible The garage is not accessible from the house and is used as a storage room; garage contained a washer and dryer, emergency food and water supply, and cleaning supplies. LPA observed a garden hose obstructing the exterior passageway. Staff cleared the obstruction during the visit. There is a side gate for emergency exit use and is single latched. There are tables and chairs for resident use. LPA advised Administrator to provide covering or shading to the outdoor seating area. No bodies of water were noted in the backyard. MEDICATION REVIEW: Beginning at 12:20PM; LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a closet at the entrance of the facility. Medications are labeled and checked for expiration dates. All medications reviewed were properly documented and accounted for; no errors observed. RECORD REVIEW: Beginning at 12:40PM, LPA reviewed six (6) out of six (6) resident files and four (4) staff files for documents including but not limited to: resident Admission Agreement, TB test, medical assessments, appraisal, health screening, staff training and fingerprint clearance. All resident and staff records reviewed were in compliance with regulation at the time of the visit. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 07/03/2026. No citations issued. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2026

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not answer call buttons in a timely manner

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 01:25PM. LPA was greeted by staff. Entrance interview conducted. Reason for the visit was explained. During today's visit, LPA conducted a brief physical plant tour, interviewed two (2) staff and three (3) out of six (6) residents between 01:32PM-02:10PM, and reviewed and obtained copies of pertinent documents. It was alleged that staff do not respond to Resident #1 (R1)’s call buttons timely. Per regulation, facilities licensed for 16 or more or having separate floors/buildings shall have a signal system. This facility is licensed for 6 and does not have separate floors or buildings. Report Continued on LIC9099-C. Unsubstantiated Although the facility is not required to have a signal system according to regulation, LPA observed three (3) out of six (6) residents with bells in their rooms. LPA interviewed the three (3) residents, including R1, and no concerns regarding staff response times were noted. Residents stated that staff are responsive and will provide assistance when residents ring the bell or call for assistance. LPA observed the three (3) residents with different types of bells and staff interviews stated this is so that staff can differentiate which resident’s bell was rung by the differing sounds. LPA interviewed the two (2) staff members present and no evidence supporting the allegation was found. Based on interview, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff do not answer call buttons in a timely manner” is deemed UNSUBSTANTIATED at this time. Staff member Evangelina Roxas was designated to sign this report. Exit interview conducted with Administrator Michelle Maurer telephonically. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 27, 2026 · control 29-AS-20260522104458

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:12AM. LPA met with staff and Licensee Ross Hashemi who arrived at 12:25PM. Entrance interview conducted. Beginning at 11:24AM, the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguisher was fully charged and last purchased 09/01/2025. All hardwired smoke and carbon monoxide detectors were tested at 11:43AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were turned off. Staff turned the alarms on during the visit and were functional and operating. KITCHEN: LPA inspected the kitchen at 11:24AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Sharp objects and cleaning supplies were stored in a locked and inaccessible cabinets. BEDROOMS/RESTROOMS: There are seven (7) bedrooms of which six (6) are private resident rooms and one (1) is a staff room. Staff room was observed to be unlocked. Five (5) rooms have exits to the exterior. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. There are three (3) restrooms, two (2) are attached to resident rooms and one (1) is in the hallway for resident, staff, and visitor use. LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in all three (3) bathrooms and were between 105.3 F-108.0 degrees F, which is within the required range. Continued on LIC 809-C. COMMON SPACES: At the time of the visit, living room and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. LPA observed ring cameras in common spaces which contain an audio component and store and save recordings. LPA telephonically advised Administrator Michelle Maurer to disconnect the cameras and submit a waiver for the Ring cameras due to the audio component, to update plan of operation, and admission agreement. LPA observed the admission agreement to state that common areas will have “video surveillance” which “will not be recorded or stored,” however, the cameras observed during today’s visit have video and audio surveillance which are recorded and stored. Staff disconnected the cameras during the visit. GARAGE/LAUNDRY/GROUNDS: The garage is not accessible from the house and is used as a storage room; garage contained a washer and dryer, emergency food and water supply, and cleaning supplies. LPA observed the garage to be unlocked and accessible, staff locked the garage during the visit. The backyard exterior passageways were clean and clear of any obstructions. There is a side gate for emergency exit use and is single latched. There are tables and chairs for resident use. No bodies of water were noted in the backyard. MEDICATION REVIEW: Medications review began at 11:50AM; medications are centrally stored and locked in a closet at the entrance of the facility. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. At 11:58AM, LPA observed a medication error for Resident #1 (R1)’s Lovastatin 20mg medication. The medication was started on 06/14/2025 with a quantity of 100 pills and instructions for one (1) pill a day. LPA observed forty-two (42) pills in the medication bottle and one (1) prepared pill for tomorrow’s administration making a total of forty-three (43) pills; however, there should be forty-seven (47) pills according to the logged start date, quantity, and the medication instructions. Four (4) pills were unaccounted for, and no documentation could be provided. RECORD REVIEW: Beginning at 12:18PM, LPA reviewed four (4) staff and five (5) out of five (5) resident files for documents including but not limited to: resident Admission Agreement, TB test, medical assessments, appraisal, health screening, staff training and fingerprint clearance. All five (5) resident files and four (4) staff records reviewed were in compliance with regulation at the time of the visit. Continued on LIC 809-C. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 06/19/2025. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Licensee was unable to be present for exit interview. Administrator designated Evangelina Roxas to sign the report. Exit interview conducted. Appeal rights and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Resident fractured their hip due to lack of care from staff

Licensing Program Analyst (LPA) Angela Barutyan conducted a subsequent complaint visit to deliver investigation finding. Upon arrival, LPA met with staff who called Administrator Michelle Mauer. Entrance interview conducted. On 01/30/2025, Community Care Licensing Division received a complaint alleging Resident #1 (R1) sustained a hip fracture due to staff neglect. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Edward Hector. On 01/31/2025, LPA T. Camara conducted an initial complaint visit to this facility for the above allegation. During the visit, LPA Camara spoke with staff at 11:23AM and spoke with the co-administrator at 11:25AM, reviewed and obtained pertinent documents at 11:37AM, conducted a brief tour of the facility/health and safety check at 11:49AM and interviewed one (1) resident at 11:50AM. CONTINUED ON LIC9099-C... Unsubstantiated On 02/07/2025, between the hours of 2PM-4PM, Investigator Hector conducted interviews with R1 and R1’s responsible party. Information gathered during the course of the investigation revealed that R1 attempted to transfer without assistance around 12:40AM on 11/15/2024, resulting in a fall. R1 requires transfer assistance and has a bell next to their bed to call staff for assistance. R1 did not ring the bell or notify staff before attempting to self-transfer. Staff immediately found R1 and called for paramedics who transferred R1 to the hospital for further evaluation. Facility notified R1’s responsible party. R1’s medical assessment dated 06/17/2024 identifies R1 as a fall risk and that R1 and care-staff shall be instructed on fall prevention measures. The facility implemented the bell next to R1’s bed to mitigate fall risk. R1’s appraisal dated 07/22/2024 and physician’s report dated 04/04/2024 document R1 as alert and social without dementia. R1 stated that the fall was not the facility’s fault and took accountability. R1’s responsible party had no concerns of lack or quality of care from staff. Based on the above information gathered, although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Resident fractured their hip due to lack of care from staff” is deemed UNSUBSTANTIATED at this time. LPA reviewed report with Administrator telephonically. Administrator was unable to be present for the visit and designated staff Lina Roxas to sign the report. No citations issued at this time. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 29-AS-20250130133758

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Michelle Maurer was contacted and arrived shortly after. The LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS/BATHROOMS: The LPA began the inspection with the bedrooms and bathrooms at 9:45 a.m. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated resident rooms and one (1) staff room. There was a linen closet in the hallway with extra towels and linens. The resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured between 111.2 and 111.3 degrees Fahrenheit between 10:15 and 10:40 a.m. KITCHEN: The LPA continued the inspection in the kitchen/food service area at 10:15 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 77 degrees. Smoke detector(s) and carbon monoxide detector were tested at 10:33 a.m. and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced September 21, 2023. The LPA observed required postings throughout the common space. Continued on LIC 809-C OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for emergency exit use and is single latched. No bodies of water noted and exits are free of obstructions at the time of visit. The garage is where the washer and dryer are held. Cleaning supplies and disinfectants are kept in locked in the garage. The LPA observed additional non-perishable food supply, emergency water and food. RECORDS: Residents’ records review began at 10:37 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records review began at 11:50 a.m. were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Emergency drills are conducted monthly with the last one conducted on 08/01/2024 of both fire and earthquake. First aid kit and supplies are sufficiently stocked. The LPA obtained the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Liability Insurance - LIC 610E Emergency and disaster plan MEDICATIONS: Medications review began at 2:45 p.m.; medications are centrally stored and locked in a closet at the entrance of the facility. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INTERVIEWS: Three (3) staff interviews were conducted with all staff demonstrating knowledge of their responsibilities and duties. Three (3) out of six (6) residents were interviewed and no concerns were noted at the time of the visit. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 27, 2024