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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609067
Report Date: 11/10/2020
Date Signed: 11/10/2020 02:37:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 VILLAFACILITY NUMBER:
197609067
ADMINISTRATOR:NAIRA KOSTANDYANFACILITY TYPE:
740
ADDRESS:44523 NORTH 15TH STREET WESTTELEPHONE:
(661) 941-4579
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:157CENSUS: 106DATE:
11/10/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jon DipalingTIME COMPLETED:
02:15 PM
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LPA Spaeth conducted a case management visit and met with Jon Dipaling, Administrator Designee at 2:00 pm. LPA Spaeth discussed the purpose of the visit was to report the findings of the investigation regarding the incident report dated 7/22/2020 that was received by CCL from the Antelope Valley Retirement Villa reporting an alleged rape. A resident reported the resident was a victim of a rape by another resident. The Lancaster Sheriff’s Department visited the facility on July 21, 2020 and a police report was filed. The police report number is #920-12GG2-1126-444.

The incident report and LPA’s findings were forwarded to the Investigative Bureau via fax. A complete investigation was conducted by IB Investigator, Eddie Hector, for Case Number LD3120-07300. The investigator interviewed the victim, the victim’s roommate, the alleged resident, and staff members from the facility. During the investigation, the investigator reviewed video surveillance footage from the facility. The camera was outside of the victim’s room and the video footage revealed no suspicious activity. The investigator reported the victim provided little corroborating information. Therefore, the IB Investigator concluded there was insufficient information to support the allegation, which is lack of supervision led to the sexual assault of the resident. At this time, Case number LD3120-07300 is unsubstantiated.

An exit interview was conducted and a copy of the report sent to Administrator Designee, Jon Dipaling, requesting the Administrator Designee’s signature. LPA Spaeth requested signed copy of the report be sent to LPA via email.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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