197609067-8-25-2022-31-AS-RRAZ-CHTHDF-20220831060613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 08/24/2022
Date Signed: 08/25/2022 09:27:18 AM

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
11/24/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20201124112200

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:	0	CENSUS: 110	DATE:	08/24/2022
		UNANNOUNCED	TIME BEGAN:	12:36 PM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Residents are engaging in verbal altercations with other residents

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unannounced visit and was greeted by the Administrator at 12:30 pm. LPA conducted a facility tour and did not observe any health or safety issues. LPA stated the purpose of the visit was to conduct a complaint which states residents are engaging in verbal altercations with other residents.

LPA interviewed staff at 1:30 pm until 1:45 pm and interviewed nine residents. LPA interviewed nine residents who stated have not witnessed residents fighting and have not witnessed residents chasing staff out of the dining room. LPA interviewed staff who stated have not witnessed residents fighting and have not experienced residents chasing staff out of the dining room. Therefore the allegation is unsubstantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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