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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602540
Report Date: 01/06/2025
Date Signed: 01/06/2025 03:03:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
02/28/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20240228142941
FACILITY NAME:PRESTIGE ASSISTED LIVING AT LANCASTERFACILITY NUMBER:
197602540
ADMINISTRATOR:MINDY MENDOZA-PERRYFACILITY TYPE:
740
ADDRESS:43454 30TH STREET WESTTELEPHONE:
(661) 949-2177
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:68CENSUS: 47DATE:
01/06/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not properly report an incident involving a resident.

INVESTIGATION FINDINGS:
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On 01/06/2025 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival LPA met with the Executive Director, Kortnie Spitznogle and LPA explained the purpose of the visit. Entrance interview conducted.

Allegation: Staff did not properly report an incident involving a resident. It is alleged resident #1(R1) had a fall within the facility, and struck their head but facility did not document the incident at the time. To investigate this allegation, LPA Rios reviewed the documents obtained by LPA Melissa Spaeth on 02/29/2024. LPA Rios also reviewed the death certificate and hospice medical records for R1 provided to Community Care Licensing Division (CCLD) on 04/25/24 from, Special Investigator Assistant, Rocio Flores. On todays visit LPA Rios requested a copy of the Unusual Incident Report involving R1 around 10/18/2023. LPA also reviewed the Death Report provided by the facility via fax on 01/18/2024. The facility reported R1's death to CCL timely and within compliance. (Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
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 6
Control Number 31-AS-20240228142941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 01/06/2025
NARRATIVE
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(Continued from LIC9099)
LPA conducted a search of an Unusual Incident Report for (R1) in CCLD's files. LPA did not find any Unusual Incident Report involving R1 for 10/18/23 or around that date. LPA's review of R1's medical record provided by the Investigation Branch (IB) revealed R1 was seen at the Antelope Valley Medical Center for a emergency on 10/18/2023. The discharge instructions revealed R1 had a humeral head fracture (a break in the upper part of the bone in the upper arm near the shoulder joint). The discharge instructions state the cause may have been from a fall. Facility was unable to provide LPA with a copy of an Unusual Incident Report for the incident in question. Although the documentation did not reveal R1 struck their head the facility did not document the incident to R1 to CCLD timely. Based on the information reviewed this allegation is deemed Substantiated at this time.

Deficiencies cited (refer to LIC9099-D). Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20240228142941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2025
Section Cited
CCR
87211(a)(1)
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(a) Each licensee shall furnish to the licensing agency... the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)...
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Facility has addressed Incident Reporting by conducting an in-house training for staff. Executive Director provided copy of training material and sign in sheet dated May 2024 to LPA. POC cleared today.
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This requirement was not met as evidence by, Based on LPA's interview, and record review the licensee failed to comply with the section cited above by not providing a written report of R1's emergency visit on 10/18/23 which posed a potential health, safety or personal rights risk to persons 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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
02/28/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20240228142941

FACILITY NAME:PRESTIGE ASSISTED LIVING AT LANCASTERFACILITY NUMBER:
197602540
ADMINISTRATOR:MINDY MENDOZA-PERRYFACILITY TYPE:
740
ADDRESS:43454 30TH STREET WESTTELEPHONE:
(661) 949-2177
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:68CENSUS: 47DATE:
01/06/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Questionable death.
INVESTIGATION FINDINGS:
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On 01/06/2025, Licensing Program Analyst Evelin Rios conducted an unannounced complaint visit to deliver findings on the above allegation. LPA Rios met with Kortnie Spitznogle and explained the reason for the visit.

On 02/28/2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding an allegation of a questionable death. It was alleged that Resident #1 (R1) had a fall within the facility, struck their head, and died shortly after. On 02/29/2024 LPA Melissa Spaeth conducted the initial unannounced complaint investigation. LPA Spaeth obtained the following documents: 1) resident roster, 2) staff work schedule, 3) staff personal phone numbers, 4) resident death reports, and 5) resident's files. On 03/07/2024, the Woodland Hills Adult Senior Care requested the Community Care Licensing Division Investigation Branch (IB) obtain death certificate and hospice medical records for R1. On 03/07/2024, Special Investigator Assistant, Rocio Flores was assigned to complete the assignment and to obtain the death certificate and hospice medical records for R1. (Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20240228142941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 01/06/2025
NARRATIVE
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On 03/14/2024, Flores obtained a copy of R1’s Death Certificate from the County of Los Angeles Department of Public Health. On 04/19/2023, Flores received R1’s Hospice medical records. LPA’s review of death certificate documented R1’s cause of death as Alzheimer's disease and dementia with behavioral disturbance.

On 04/23/24, Flores reviewed Hospice records for R1. Records indicated that on October 18, 2023, R1 received medical care from the Antelope Valley Medical Center for a fall incident that occurred at this facility. Antelope Valley Medical Center discharge instructions did not indicate R1 struck their head. On 11/07/23, R1 started receiving Hospice services, at the time of admission for Hospice R1 was diagnosed terminally ill; Alzheimer dementia, Hypertension, Chronic Kidney disease, diabetes, and anemia, and had a prognosis of 6 months or less. LPA Rios review of the documents obtained by IB found no clear link between R1’s fall on 10/18/23, and subsequent death on 01/16/2024.

Based on the information obtained, there is insufficient evidence to support the allegation, therefore the allegation of Questionable death is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6