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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 07/28/2022
Date Signed: 07/29/2022 08:53:41 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
07/31/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20200731134509
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: 115DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jon Dipaling TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident eloped from facility
Facility staff do not have accurate resident records
Facility staff did not develop a care plan to prevent resident from eloping multiple times
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit and was met by Administrator. LPA Spaeth explained the purpose of the visit was to conduct an investigation regarding the alleged complaints listed above. LPA confirmed there are 115 residents at the facility. LPA reviewed resident's file from 11:30 until 12:30 pm. and LPA interviewed staff member from 1:00 to 1:30pm.
In regard to the allegation, resident eloped from facility, LPA received a copy of the Physician's Report which states resident is able to leave facility unassisted. LPA received a copy of the Sheriff's Department report which states facility did file a missing persons report. This allegation is unsubstantiated.
In regard to facility staff do not have accurate resident records is unsubstantiated. LPA reviewed the resident records and observed the facility had previously obtained the hospital records for the resident in question. LPA observed all resident records were correct.
LPA Spaeth reviewed resident’s records and observed a Pre-Placement Assessment was completed and two Service Care Plans were completed on March 25, 2020 and April 15, 2020. The allegation, facility staff did not develop a care plan to prevent resident from eloping multiple times 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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
07/31/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20200731134509

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: 100DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jessica Pelaya TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff did not report resident missing.
INVESTIGATION FINDINGS:
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LPA reviewed incident reports received from the facility staff and observed there was no incident report submitted to Community Care Licensing, reporting resident was missing. The allegation that states facility staff did not report resident missing is substantiated.

Based upon LPA's review of the faclity records, 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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-20200731134509
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: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2022
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) (a) Each licensee shall furnish to the licensing agency such reports .. the following: (1) A written report shall be submitted to the licensing agency of the occurrence of any of the events ..(D) any incident which threatens the welfare, safety or health of any resident….
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Administrator will ensure incident reports are sent to CCL.
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This was evidenced by: CCL did not receive an Incident Report sating R1 was AWOL from the facility which poses an immediate health and safety 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: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3