197609067-8-12-2022-31-AS-TAGD-CWRPS6-20231019113349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 08/10/2022
Date Signed: 08/12/2022 10:19:35 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
11/19/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20201119122701

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:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Jessica Pelaya		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are being physically abused by another resident
Facility is not following reporting requirements

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 residents are being physically abused by another resident and facility is not following reporting requirements. LPA confirmed the complaint was submitted during 2020 which was the time the facility was Antelope Valley Retirement Villa.
LPA interviewed the Administrator Designee and three staff members regarding incidents that allegedly occurred between three named residents. The three staff members stated the three residents mentioned dd not participate in altercations. Also, LPA interviewed one of the three residents mentioned who stated did not participate in altercations with the other two residents. This allegation is unsubstantiated.
In regard to facility is not following reporting requirements is unsubstantiated. LPA interviewed Complainant who stated did not remember making that statement. Also, LPA interviewed staff who stated have been following COVID-19 requirements.
Exit interview conducted, appeal rights discussed, and a copy of the report was given to 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: 08/10/2022

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)

Page: 1 of 1