197609067-10-7-2020-31-AS-CHAS-BUVTUK-20201030150228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 10/07/2020
Date Signed: 10/07/2020 01:03:29 PM

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
05/08/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20200508101424

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:	157	CENSUS: 108	DATE:	10/07/2020
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Jon Dipaling		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was physically abused while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Spaeth initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted as a FaceTime visit with Jon Dipaling, the Administrator Designee for Antelope Valley Retirement Villa. LPA Spaeth explained the purpose of the visit was to report LPA’s findings regarding the allegation listed above.

In regard to the allegation a resident was physically abused while in care, LPA interviewed the resident in question. Resident stated on 5/06/2020 while sleeping in bed, someone was hitting resident in the chest. Resident stated woke up but could not see who was hitting resident. Resident stated it was dark and could not see. LPA interviewed resident’s roommate and asked if resident's roommate had ever witnessed another resident or staff member had previously entered the room and attacked

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: 10/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2020

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 2

Control Number 31-AS-20200508101424

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: 10/07/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

roommate. Resident's roommate stated no. LPA asked resident's roommate if ever witnessed another resident enter the room uninvited. Resident's roommate stated no. LPA aked if resident's roommate has ever hit another resident or another staff member. Resident stated no.

LPA spoke to the caregiver who worked the night shift on 5/06/2020 but caregiver stated resident did not report anyone attacking resident in room. Also, caregiver stated checked room every two hours and never witnessed anyone entering another resident’s room without an invite. LPA spoke to Administrator Designee, Jon Dipaling who stated had not received a report from the resident mentioned in the allegation stating someone had entered room and attacked resident. Administrator Designee stated there are has not been any incidents of assault reported for the resident mentioned in the allegation and the resident's roommate. Administrator Designee stated both residents are calm and never aggressive. LPA also interviewed several residents who stated never experienced a resident entering room and attacking resident. Therefore, the complaint stating resident was physically abused while in care is unsubstantiated.

A FaceTime exit interview was conducted with Administrator, and a hard copy was provided via email to the Administrator Designee. LPA requested Administrator Designee to send signed report to LPA via email.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2