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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602540
Report Date: 02/03/2025
Date Signed: 02/03/2025 04:35:27 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: 46DATE:
02/03/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kortnie Spitznogle and Analilia ZaragozaTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff do not provide adequate transportation service for the residents.
INVESTIGATION FINDINGS:
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On 02/03/2025 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.

At approximately 10:24 a.m. LPA, along with a Director of Health and Wellness, Jesse Wong observed the transportation vehicle. According to Jesse the vehicle sits eight individuals not including the driver. LPA obtained a copy of the vans registration.

Allegation: Staff do not provide adequate transportation service for the residents. It is alleged the facility does not have a properly licensed driver or adequate transportation for residents. To investigate this allegation LPA Rios conducted an unannounced subsequent visit on 03/28/2024, LPA obtained a copy of the desiganted driver's driver license and insurance identification card. LPA also conducted interviews 2:30 p.m. to 3:35 p.m. LPA with five (5) residents and three (3) staff. (Continue to LIC9099)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
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: 02/03/2025
NARRATIVE
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(Continued from LIC9099) A review of the facility’s own Program Descriptions, under XII. Transportation arrangement states, "Prestige Assisted Living at Lancaster will have a wheelchair assessable van that will be utilized for transporting residents as needed to medical and dental appointments. It shall also be used for transportation to community activities and on Community business. Only licensed drivers shall be permitted to drive the van. The seating capacity of the van (13) shall not be exceeded". LPA's observation of the vehicle is that it now sits 8 residents. Review of vehicle registration for 01/31/2024 to 01/31/2025 and for the previous year have type vehicle use as "commercial". Review of drivers license for the designated driver at the time has no endorsements listed. An endorsement (P) is required to operate a passenger vehicle. Based on records and observation this allegation is deemed Substantiated at this time.

Deficiency cited (refer to LIC9099-D). Appeals provided. Copy of report provided.

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

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 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: 46DATE:
02/03/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kortnie Spitznogle and Analilia ZaragozaTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are not providing adequate laundry services.
Staff are mishandling the residents’ personal belongings.
Staff spoke inappropriately towards a resident.
Facility did not abide by the admission agreement.
INVESTIGATION FINDINGS:
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On 02/03/25 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.

LPA Rios conducted a physical plant tour at approximately 1:45 p.m., LPA did not observe any health or safety issues. While conducting a physical plant tour LPA conducted a follow-up interview with one (1) resident that was interviewed on 03/28/24 and follow-up interviews with (2) residents that were interviewed on 01/06/25. On todays visit LPA conducted two (2) more resident interviews with residents that had not been previously interviewed during initial visits made for this investigation.

Allegation: Staff are not providing adequate laundry services. It is alleged residents' personal laundry is not being laundered. (Continued on LIC9099-C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 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: 02/03/2025
NARRATIVE
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(Continued from LIC9099-A) To investigate the allegation LPA Rios conducted a physical plant tour at approximately 2:00 p.m., on 03/28/24. LPA Rios also conducted interviews from 2:30 p.m. to 3:35 p.m., with five (5) residents and three (3) staff. On 01/06/25 at 2:22 p.m., LPA Rios toured the physical plant of the facility focusing on the four (4) laundry rooms. LPA Rios also interviewed two (2) out of three (3) residents that were approached during physical plant tour. One (1) resident did not respond to LPA's questions. On 02/03/25, LPA reviewed facility's own Service and Rental Agreement regarding Laundry Service and interviewed two (2) more residents. Interviews with nine (9) out nine (9) residents that provided information during interviews corroborate not having any issues concerning laundry being laundered. Based on resident interviews and record review this allegation is deemed Unsubstantiated at this time.

Allegation: Staff are mishandling the residents’ personal belongings. It is alleged residents' personal laundry is not being, delivered back to them or completely disappearing. Similar to the allegation above, to investigate the allegation LPA Rios conducted a physical plant tour on 03/28/24, LPA Rios also conducted interviews from with five (5) residents and three (3) staff. On 01/06/25 LPA Rios toured the physical plant of the facility and interviewed two (2) out of three residents that were approached during physical plant tour. One (1) resident did not respond to LPA's questions. On 02/03/2025, LPA reviewed facility's own Service and Rental Agreement regarding Laundry Service and Theft and Loss Prevention Program. LPA also reviewed the Resident's Handbook regarding Theft and Loss. LPA's interviews with eight (8) out of nine (9) residents that provided information for the allegation corroborate not having any issues concerning laundry being returned to them when completed. One (1) resident that provided information on 01/06/24 however did state they had personal towels go missing about a year ago and reported it to housekeeping. Resident #6 (R6) states it is no longer an issue. Based on resident interviews this allegation is deemed Unsubstantiated at this time.

Allegation: Staff spoke inappropriately towards a resident. It is alleged residents are sternly spoken to by caregivers.

(Continued on LIC9099-C) Page 2 of 3

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

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
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: 02/03/2025
NARRATIVE
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(Continued from LIC9099-C) To investigate the allegation on 03/28/24, LPA Rios conducted interviews from 2:30 p.m. to 3:35 p.m., with five (5) residents and three (3) staff. On 01/06/25, LPA Rios interviewed two (2) out of three (3) residents that were approached during physical plant tour. One (1) resident did not respond to LPA's questions. On 02/03/25, LPA interviewed two (2) residents not previously interviewed. Interviews with eight (8) out nine (9) residents that provided information did not express issues with the way staff spoke to them directly. One (1) out of the nine (9) residents did have concerns of staff using a phrase made near them they believed to be insulting based on their religion. Based on resident interviews this allegation is deemed Unsubstantiated at this time.

Allegation: Facility did not abide by the admission agreement. It is alleged the facility only provided services such as meals and medication management, and that residents were on their own for other needs. To investigate the allegation on 03/28/24, LPA Rios conducted interviews from 2:30 p.m. to 3:35 p.m., with five (5) residents and three (3) staff. On 01/06/25, LPA Rios interviewed two (2) out of three (3) residents that were approached during physical plant tour. One (1) resident did not respond to LPA's questions. On 02/03/25, LPA interviewed two (2) residents not previously interviewed. On 02/29/24, LPA Spaeth obtained copies of various residents' admission agreements. On 02/03/25, LPA reviewed facility's admission agreement provided to Community Care Licensing Division (CCLD) and compared it to those obtained by LPA Spaeth. Interviews with eight (8) out nine (9) residents that provided information did not express having issues or concerns related to the basic services agreed upon at admissions. The eight (8) residents corroborated the facility has provided such services. Based on resident interviews and record review this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report provided. Page 3 of 3

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

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 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: 02/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87208(a)(8)
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87208 (a)(8) Plan of Operation
"Each facility shall have and maintain...Any significant changes ...which would affect the services to residents shall be submitted to the licensing agency for approval.The plan and related materials shall contain the following: (8)Transportation arrangements for persons served who do not have independent arrangements. This requirement was not met as evidenced by:
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Administrator will submit updated plan of operation to Community Care Licensing by POC due date.
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Based on record review, the facility did not adhere to its plan of operation regarding the vehicle used for transportation and the licensed driver which poses a potential risk to the health, safety, or personal rights of clients 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: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6