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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 08/03/2022
Date Signed: 08/08/2022 02:15:37 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/12/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20200612112027
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:0CENSUS: 112DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jon Dipaling TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9

Staff are not providing adequate food service
Staff denied resident access to CCL facility number
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit and met with Administrator. LPA explained the purpose of the visit was to conduct a complaint investigation. LPA also explained the alleged allegations were staff did not prevent physical altercation between residents, staff are not providing adequate food service, and staff denied resident access to community care licensing number. LPA conducted a physical plant tour and did not observe any health and safety issues. LPA interviewed residents from 10:45 am until 12:45 am.

LPA interviewed eleven residents who stated receive an adequate supply of food and water. Residents stated facility provides snacks during the day. Therefore, the allegation is unsubstantiated.

During LPA's tour of the facility, LPA observed the Let Us Know sign is visible within the facility. Also, LPA spoke to Administrator Designee who stated never received a request from a resident wanting the CCL facility number. The allegation staff denied resident access to CCL facility number is unsubstantiated.

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

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/12/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20200612112027

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:0CENSUS: 112DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jon DipalingTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting resident's needs.
Staff did not prevent physical altercation between residents
INVESTIGATION FINDINGS:
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LPA interviewed previous Administrator Designee about the altercation incident occurred between two residents during June 2020 in which resident had a pipe hidden in room. Police were called & arrived. R1 and R2 stopped fighting because staff hurried to the location to stop the fight. R2 stated R1 hit R2 on the elbow with the pipe. Therefore the allegation, staff did not prevent physical altercation between residents is substantiated.

LPA confirmed with Administrator there are no residents with bed sores at this time. RP stated there are residents that have bed sores. RP stated that residents wear diapers which are falling off and incontinent needs were not met. LPA interviewed four residents who need assistance with incontinent needs. Three of the four stated the night shift does not always assist residents with diaper needs. Therefore the allegation staff are not meeting resident's needs is substantiated. Based upon LPA's observations and staff interviews, the allegation is substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.

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

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20200612112027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
HSC
1569.2(c)
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Health & Safety 1569.2(c) (c) "Care and supervision" ..the facility assumes responsibility for, or provides .. assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
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Administrator Designee will implement a plan and training of staff regarding resident screening when entering the building.
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This is evidenced by: Based upon LPA's interview of Administrator Designee, R1 brought into a faciilty a pipe which was used as a weapon, which is an immediate health and safety risk to residents in care.
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Type B
08/12/2022
Section Cited
CCR
87625(a)(1)(D)
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87625 Managed Incontinence (b) In addition to Section 87611, .., the licensee shall be responsible for the following: (1) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
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Administrator Designee stated will implement a plan and training of night staff regarding incontinent needs.
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This is evidenced by: LPA interviewed three resdients who have incontienent needs who stated night caregiver staff at times does not check on reisdents during the night to determine if need diaper changed which is an immedaite health and safgety risk to residents 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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3