Leisure Living Inc.

Allegation investigated: Staff do not ensure resident's basic needs are met

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 11:10AM. Upon arrival, LPA met with House Manager Tina Santos. Entrance interview conducted. During today’s visit, LPA conducted a brief physical plant tour, interviewed one (1) staff member and one (1) resident, and reviewed and obtained copies of pertinent documents. During the initial visit on 05/21/2026, LPA conducted a brief physical plant tour, conducted interviews with two (2) staff members, two (2) residents, and attempted three (3) resident interviews, and reviewed and obtained copies of pertinent documents relevant to the investigation. REPORT CONTINUED ON LIC9099-C. Unsubstantiated It was alleged that staff do not provide Resident #1 (R1) with basic needs such as showers and hair grooming. LPA interviewed six (6) out of six (6) residents and no concerns regarding unmet basic needs were noted. Residents appeared clean and no health and safety concerns were observed. Three (3) out of the three (3) residents who were capable of verbal interviews, including R1, stated that they are offered and provided showers by facility staff. Residents stated that showers are on a consistent schedule to be provided at least two (2) times a week. Two (2) out of the three (3) residents stated they like the showers provided by facility staff. R1 stated that they refuse full body showers because of concerns of falling. R1 stated that they are offered and provided with bed baths to accommodate, however, their hair does not get washed. R1 and staff interviewed stated that R1’s hair gets washed in the shower and cannot be washed during the bed bath. Due to shower refusals, R1’s hair had not been washed since February 2026. Staff stated that they encourage R1 to shower so that their hair can be washed and have contacted outside agencies to provide additional resources and support to R1. R1 confirmed that staff consistently encourage showers for hair washing, however, R1 does not feel safe to go into the bathroom for a standing or sitting shower. During today’s visit, LPA observed a hair washing funnel and a portable hair washing basin that were purchased by the facility for washing R1’s hair without having to get out of bed. Staff interviewed stated that R1 still refuses hair washing. LPA observed logs of documented refusals. LPA contacted R1’s responsible party and the Long-Term Care Ombusdman throughout the investigation and no evidence supporting the allegation was noted. Therefore, based on interview, observation, and record review, 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 ensure resident's basic needs are met” is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 29-AS-20260515082518

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived unannounced to conduct a required annual visit at 10:28AM. LPA met with staff and explained the reason for the visit. Administrator Michelle Maurer arrived during the visit at 11AM. Entrance interview conducted. 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. The following was observed: KITCHEN: The LPA inspected the kitchen/food service area at 10:31AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for expiration dates; food labels had expiration date clearly marked. Knives and sharps are stored locked and inaccessible to residents in care. BEDROOMS: There are five (5) resident bedrooms. Four (4) bedrooms are single occupancy, and one (1) bedroom is double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a locked staff room on the premises by the garage. RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the hallway and the second restroom is located in Bedroom #1. Restrooms were clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in restrooms and were between 113.0-118.4 degrees F, which is within the required range. Report Continued on LIC 809C. COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature. The hardwired smoke detector(s) and carbon monoxide detector were tested at 11:09AM and all were operational at the time of the visit. The fire extinguisher was fully charged and last purchased on 08/14/2025. The LPA observed required postings throughout the common space. All auditory exit devices in common areas and bedrooms were functional and operating at the time of the visit. OUTDOORS/GARAGE/LAUNDRY: The garage is kept locked at all times. The facility has an adequate supply of emergency food and water which was observed to be in good condition. The washer and dryer were observed inside the garage inaccessible to residents in care. Detergents and cleaning solutions were observed locked and inaccessible. The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There is one (1) self-latching gate. No bodies of water were noted at the time of the visit. RECORD REVIEW: Beginning at 11:15AM, LPA reviewed six (6) out of six (6) resident and four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, and fingerprint clearance. All resident and personnel files were in order. MEDICATIONS: At 12:20PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a cabinet by the kitchen area. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs were properly documented and logged. Medications were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law. 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 drills are conducted quarterly as required, with the last drill conducted on 11/02/2025. Exit interview conducted. No deficiencies issued. A copy of the report provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived unannounced to conduct a required annual visit at 10:08AM. LPA met with staff and explained the reason for the visit. Administrator Michelle Maurer arrived during the visit at 10:33AM. Entrance interview conducted. At 10:11AM, the LPA along with the 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. KITCHEN: The LPA inspected the kitchen/food service area at 10:11AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps are stored in a cabinet next to the stove inaccessible to residents in care. BEDROOMS: There are five (5) resident bedrooms. Four (4) bedrooms are single occupancy, and one (1) bedroom is double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a locked staff room on premises by the garage. RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the hallway and the second restroom is located in bedroom #1. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Between 10:21AM – 10:23AM, hot water temperatures were measured in both bathrooms and were between 117.2 degrees F – 117.7 degrees F, which is within the required range. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector are hard-wired and were tested at 10:26AM; all were operational at the time of the visit. The fire extinguisher was fully charged and last purchased on 09/01/2024. The LPA observed required postings throughout the common space. GARAGE/BACKYARD: The garage is kept locked at all times. The facility has an adequate supply of emergency food and water which was observed to be in good condition. The washer and dryer were observed inside the garage inaccessible to residents in care. Detergents and cleaning solutions were observed locked and inaccessible. The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There is one (1) gate with self-latching and self-closing mechanisms observed. Auditory alarms were observed functioning at the time of the visit but were turned off to keep the door open. Administrator stated they will replace the auditory alarms to ones that allow the doors to be left open without the alarms having to be turned off. No bodies of water were noted at the time of the visit. MEDICATIONS: Medications review began at approximately 10:34AM; medications are centrally stored and locked in a closet by the kitchen. LPA reviewed medications for three (3) residents and observed all medications including PRNs to be labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. 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. RECORD REVIEW: Beginning at 10:57AM, LPA reviewed six (6) out of six (6) resident and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) 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 drills are conducted quarterly as is required, with the last drill conducted on 11/02/2024. At the time of the visit, the LPA obtained the following documents: LIC 500 Personnel Report, LIC9020 Client Roster, and a copy of the liability insurance. Exit interview conducted. No deficiencies issued. A copy of the report provided.the state’s words, verbatim · CDSS document, Nov 15, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 9:20 a.m. The last annual conducted at this facility was on 09/30/2022. When the LPA arrived, there were three (3) staff and five (5) residents present. The LPA was greeted at the door by staff Cristina Santos and the reason for the visit was explained. The Administrator, Michelle Maurer and the Licensee Representative, Razi Hashemi arrived shortly after. Entrance interview conducted. At 9:45 a.m., the LPA along with the Administrator 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. KITCHEN: The LPA inspected the kitchen/food service area at 9:54 p.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps are stored in a cabinet next to the stove inaccessible to residents in care. At 10:04 a.m., the water temperature was tested in the kitchen faucet, and it measured 122.9 degrees Fahrenheit. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector are hard-wired and were tested and operational at the time of the visit. The fire extinguisher was observed to be purchased on 09/21/2023. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) The LPA observed reading books and puzzles in the living room. The LPA observed required postings throughout the common space. Facility license observed posted; however, information does not reflect current hospice waiver approved by the department. The LPA issued updated license to the facility. GARAGE/BACKYARD: The garage is kept locked at all times. The facility has an adequate supply of emergency food and water which was observed to be in good condition. The washer and dryer were observed inside the garage inaccessible to residents in care. Detergents and cleaning solutions were observed locked an inaccessible. The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There is one (1) gate with self-latching mechanisms observed. Auditory alarms were observed functioning at the time of the visit. No bodies of water were noted at the time of the visit. BEDROOMS: There are five (5) resident bedrooms. Four (4) bedrooms are single occupancy, and one (1) bedroom is double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a staff room on premises. RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the hallway and the second restroom is located in bedroom #6. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The LPA observed a cabinet in bathroom #1 with extra towels and linens. The hot water temperature was measured in both bathrooms; the first bathroom measured 123.6 degrees Fahrenheit at 9:49 a.m.; and the second bathroom measured 116.7 degrees Fahrenheit at 9:52 a.m. The staff adjusted the water temperature at the time of the visit. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) RECORDS: Records review began at 10:11 a.m.; five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All resident records were in order. Four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All personnel files were in order. The last emergency disaster drill took place on 11/02/2023. At the time of the visit, the LPA obtained the following documents: LIC 500 Personnel Report, LIC9020 Client Roster, and a copy of the liability insurance. The LPA conducted interviews with two (2) staff member between 12:00 p.m. and 12:20 p.m. MEDICATIONS: Medications review began at approximately 12:25 p.m.; medications are centrally stored and locked in a closet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. 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. Exit interview conducted. No deficiencies issued. The report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Nov 13, 2023

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.