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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609067
Report Date: 07/23/2020
Date Signed: 07/23/2020 03:03:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANTELOPE VALLEY RETIREMENT VILLAFACILITY NUMBER:
197609067
ADMINISTRATOR:NAIRA KOSTANDYANFACILITY TYPE:
740
ADDRESS:44523 NORTH 15TH STREET WESTTELEPHONE:
(661) 941-4579
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:157CENSUS: 103DATE:
07/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jon DipalingTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted a Case Management - Incident visit. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted as a virtual tour using FaceTime with Jon Dipaling, the Administrator Designee for the facility.

On July 21, 2020, the department received an incident report and SOC341 stating there was an alleged incident on July 20, 2020 relating to a resident's personal rights. The incident was referred to and accepted by Community Care Licensing Divisions (CCLD’s) Investigations Branch (IB). Investigator E. Hector accompanied LPA Spaeth during the FaceTime tour.

LPA Spaeth and Investigator Hector with the assistance of the Administrator Designee toured the physical plant. LPA viewed required COVID-19 postings throughout the facility, a sign in sheet at the front entrance, and hand sanitizer for residents' use throughout the facility. LPA observed staff were wearing masks while completing daily job duties within the facility. LPA observed some residents were not wearing masks in facility public areas but observed the Administrator Designee reminded the residents to wear a mask. LPA observed kitchen staff preparing salad and a ham sandwich for the residents which will be delivered to each residents' room. Kitchen staff also stated the dinner menu will be beef, baked potato with mixed vegetables. LPA also observed three resident rooms while conducting the tour. Each room was properly furnished with a bed, night stand, lamp, and chair in each room. LPA also viewed an adequate number of PPE supplies were available for staff members and masks for residents.

No citations will be issued at today’s visit. Exit interview conducted, and a copy of the report was sent by email to the Administrator Designee.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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