197609067-2-23-2023-31-AS-TAGD-CT2NYV-20230622105318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 08/03/2022
Date Signed: 02/23/2023 10:43:56 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
08/19/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20200819125746

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: 112	DATE:	08/03/2022
		UNANNOUNCED	TIME BEGAN:	03:31 PM
MET WITH:	Jon Dipaling		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility does not have hot water.
Facility is not kept clean and sanitary.
Facility did not provide adequate personal care and hygiene supplies to resident(s).
Facility is not conducting fire drills as required.

INVESTIGATION FINDINGS:

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This is an amendment of the original report issued 08-03-2022 to correct times of observation, remove documentation of an allegation that was not a part of the original complaint and add details to the last allegation. LPA Spaeth conducted a subsequent unannounced visit and met with Administrator. LPA explained the purpose of the visit. LPA conducted a facility tour from 10:15 am until 10:45 am. In regard to facility does not have hot water, At 3:35 pm, LPA checked water temperature which was 104.0 F. LPA also interviewed eleven residents from 3:45 until 5:30 pm who stated the water temperature was warm. Therefore, the allegation is unsubstantiated.
LPA Spaeth interviewed eleven residents who stated rooms are cleaned by cleaning staff each day. At 3:45 pm LPA observed cleaning staff member mopping a resident's room. Therefore, the allegation, facility is not kept clean and sanitary is unsubstantiated.
LPA Spaeth spoke to eleven residents who stated facility staff provide an adequate supply of hygiene items. LPA checked seven residents' bathrooms and observed hand soap, paper towels, and a trash can. At 3:35 pm, LPA observed an adequate supply of personal hygiene items locked in a facility closet. Therefore, the allegation Facility did not provide adequate personal care and hygiene supplies to residents is unsubstantiated.

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: 08/03/2022

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)

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Control Number 31-AS-20200819125746

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
	VISIT DATE: 08/03/2022

NARRATIVE

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The allegation, facility is not conducting fire drills as required is unsubstantiated. LPA received copies of documentation which states facility had conducted the required fire drills. Please include how often the fire drills.
The allegation, facility is not conducting fire drills as required is unsubstantiated. LPA received copies of documentation which states facility had conducted the required fire drills.

Exit interview was conducted and a copy of the report was given to the Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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