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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191222665
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:15:09 PM

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
06/06/2023 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230606153238
FACILITY NAME:ANTELOPE VALLEY CARE HOMEFACILITY NUMBER:
191222665
ADMINISTRATOR:BIBIANA, LARAFACILITY TYPE:
735
ADDRESS:40712 171ST STREET EASTTELEPHONE:
(661) 264-3341
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 3DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marie Lara-BruTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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1. Client was not given meals all day
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility at 11am to conduct an unannounced complaint visit. LPA arrived to the facility and heard Latin music blasting from the facility. LPA knocked on the door and rang the bell several times and no-one responded. LPA contacted the Administrator Marie Lara-Bru, who informed LPA she was at the doctor's office; clients were at day program, and she would be come to the facility after the appointment.

Administrator arrived at the facility at 12pm. LPA interviewed staff and clients, as well as conducted a physical plant inspection of the facility's food supply,from 12pm to 330pm. LPA observed the facility was in compliance, and there an abundance of fresh fruit and snacks for clients. During interviews, it was reported that clients receive (3) meals and (2) snacks per day, and have several outings a week, where clients are taken to there favorite resturant. Although it was reported cleint #1 (C1) was not given any meals on one particular day, but there was not a specific date or time, when the alleged incident occurred. Staff reported to LPA, that C1 would often often miss meals, because C1 preferred to sleep, and meals were kept in the
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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-20230606153238
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: ANTELOPE VALLEY CARE HOME
FACILITY NUMBER: 191222665
VISIT DATE: 06/14/2023
NARRATIVE
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refrigerator or microwave for C1 whenever C1 was ready to eat. Therefore, based on interviews and observations, the allegation is deemed UNSUBSTANTIATED at this time.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3