197609067-10-1-2020-31-AS-MSPH-BTYT4L-20201001142406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609067
Report Date: 10/01/2020
Date Signed: 10/01/2020 02:25:56 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 VILLA		FACILITY NUMBER:	197609067
ADMINISTRATOR:	NAIRA KOSTANDYAN		FACILITY TYPE:	740
ADDRESS:	44523 NORTH 15TH STREET WEST		TELEPHONE:	(661) 941-4579
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	157	CENSUS: 106	DATE:	10/01/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Jon Dipaling		TIME COMPLETED:	09:45 AM

NARRATIVE

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Licensing Program Analyst (LPA) Spaeth and Licensing Program Manager (LPM) Cassandra Harris, initiated a case management visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management visit was conducted as a virtual tour using FaceTime with Jon Dipaling, the Administrator Designee for Antelope Valley Retirement Villa. LPA Spaeth explained the purpose of the visit was to conduct a case management visit and to view the facility’s COVID-19 procedures.

At 8:05 am, LPA, LPM, and Jon Dipaling toured the dining hall. Upon viewing the dining hall, LPA observed residents on the right side of the room who were social distanced eating breakfast. However, on the left side of the room, LPA observed five residents at a long table who were not socially distanced. Dipaling explained when the dining hall opened, the five residents went to the table to wait. LPA observed as staff members were requesting some of residents to move to another table. Upon leaving the dining room, LPA and LPM observed residents who were not social distanced while waiting to enter the dining hall. Also LPA and LPM observed there was not a staff member in the hallway advising residents to observe proper distancing while waiting. LPA and LPM discussed with Dipaling a care giver should be in the hallway reminding residents to follow the social distancing guidelines. LPM also advised Dipaling hand sanitizer and additional masks will need to be available when care giver is observing the residents in the hallway waiting for meals.

Dipaling then entered the first floor public bathroom at 8:15 am. LPA and LPM observed the bathroom did not contain paper towels. Dipaling then supplied paper towels for the bathroom. LPM and LPA observed a paper towel

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 VILLA	FACILITY NUMBER: 197609067
	VISIT DATE: 10/01/2020

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dispenser and soap dispenser on the wall. Dipaling stated the wrong dispensers were installed by the facility; however, Dipaling stated will order the correct dispensers for the bathroom.

Dipaling went to the second level of the building and entered the staff bathroom. LPA and LPM observed the staff bathroom contained hand soap and paper towels. LPA requested to view Room 237. Upon entering, LPA and LPM observed resident walking out of the bathroom. LPA and LPM observed there were no paper towels in the bathroom but did contain soap. Dipaling instructed a staff member to supply towels for bathroom located in Room 237. The bathrooms in Room 220 and Room 243 were both checked but the bathrooms did not contain paper towels.

Dipaling proceeded to the first floor the facility and checked rooms 106 and 109, which both contained soap and paper towels. However, when room 113 was checked, there were no paper towels or soap in the bathroom.

LPA and LPM then viewed the PPE supplies that are stored in the administrative office. Dipaling then stated there were 2,100 surgical masks and stated an order has been placed for additional masks. LPA requested Dipaling advise LPA when the order is to be received. LPA and LPM observed N95 masks and an adequate supply of gloves and gowns. Dipaling then walked to the dining room and LPA observed the dining hall was empty. Dipaling stated residents had eaten breakfast and left the dining hall.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D). Exit interview was conducted, appeal rights discussed, and a copy of the repot was issued to Dipaling by email.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 VILLA	FACILITY NUMBER: 197609067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/12/2020 Section Cited	1 2 3 4 5 6 7	87307 Personal Accommodations & Services(a)Living accommodations & grounds shall be related to the facility's function...The following provisions shall apply: (3) Equipment & supplies necessary for personal care & maintenance of adequate
	8 9 10 11 12 13 14	hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen...hand towels....(D) Hygiene items of general use such as soap and toilet paper. Based on the FaceTime tour conducted, the tour revealed the facility was not providing an adequate supply of hygiene items such as paper towels and hand soap. Upon eight resident rooms, LPA and LPM observed only two resident rooms were properly supplied with hand soap and paper towels.	8 9 10 11 12 13 14
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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.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

LIC809 (FAS) - (06/04)

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