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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 08/24/2022
Date Signed: 08/25/2022 04:12:26 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
12/09/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20201209142312
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: 110DATE:
08/24/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica PelayaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to contact authorized representative
Facility failed to return residents belonging.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Spaeth conducted an unannounced visit and was greeted by the Administrator at 9:30 am. AT 9:45 am, 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 facility failed to contact authorized representative and facility failed to return residents belonging. LPA interviewed staff members 10:00 am until 10:30 am. LPA reviewed resident's file at 11:00 am. In regard to facility failed to contact authorized representative, LPA confirmed with the Administrator that the conservator was contacted when resident was admitted to the hospital. Administrator also stated the resident's conservator was not a family member. Administrator also stated that family members were called, a message was left but family members did not return call. Therefore, the allegation is unsubstantiated.
In regard to allegation, facility failed to return resident's belongings is also unsbustantiated. The complainant stated the scooter was not returned to the family after the resident moved out. The previous Administrator and current Administrator confirmed the resident no longer used the scooter and did not want the scooter. Also, LPA observed the scooter was still locked in storage within the facility. . Exit inteview conducted, appeal rights discuseed, and a copy of the report was given to the Administrator.
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: 08/24/2022
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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