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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 08/10/2022
Date Signed: 08/15/2022 07:44:59 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
10/26/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20201026125129
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: DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
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9
Staff ran resident into a doorway causing an injury
Staff did not provide medical attention to resident
Staff was rough with resident
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 Administrator. LPA stated the purpose of the visit was to investigate a complaint which states staff ran resident into a doorway causing injury, staff did not provide medical attention to resident, and staff was rough with resident. LPA confirmed the complaint was submitted during 2020 which was the time the facility was Antelope Valley Retirement Villa.

LPA interviewed two staff members at 12:10 pm until 12:45 pm. The two staff members stated Complainant's friend (R2) obtained a skinned hand when a caregiver was wheeling the R2 out of room. Both staff members stated the incident was an accident and staff member apologized for incident. Both staff members also stated the wound was small and staff immediately treated the wound. Also staff members stated the wound did heal.
LPA obtained a copy of R2's death report which did not state the resident was septic when died. Therefore, the three allegations are 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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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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