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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 04/12/2021
Date Signed: 04/12/2021 03:57:11 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
05/13/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20200513134405
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: 98DATE:
04/12/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Jon DipalingTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff failed to ensure resident is properly fed.
Staff failed to supply resident with hygiene product.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Melissa Spaeth (LPA) initiated a complaint investigation for the allegations 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 tele-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 allegations listed above.

In regard to the allegation staff failed to supply resident with hygiene products. LPA Spaeth spoke to resident (R1) mentioned in the complaint on June 25, 2020 at 4:00 pm. R1 stated had asked for hygiene item from facility staff but it took two weeks for facility staff to provide needed item. LPA Spaeth interviewed two residents on May 28, 2020, R4 at 11:30 am and R5 at 9:45 am. Both residents stated asked for hygiene items from facility staff but were informed facility was out of the specific hygiene item.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
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 4
Control Number 31-AS-20200513134405
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: 04/12/2021
NARRATIVE
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LPA Spaeth conducted a virtual Face Time tour in regard to complaint #31-AS-20200917140123 on 9/24/2020 at 10:00 am. with Administrator Designee. At 10:35 am, LPA Spaeth asked to see hygiene items available for residents. Administrator Designee showed LPA the supply closet in Administrative office of the facility. LPA Spaeth observed there were no toothbrushes and no hand soap available for the residents.

LPA Spaeth previously completed a FaceTime tour of the facility on October 5, 2020 and concluded the complaint was unsubstantiated. However, additional interviews were conducted on March 19, 2021 and LPA Spaeth spoke to four residents. One Resident (R2) was interviewed at 10:00 am who stated asked for second helpings during the month of May, 2020 but was told by staff there was not enough food to offer second helpings. Two other residents stated had not asked for second helpings but receives enough food to eat during meals.

Resident (R4) was interviewed on May 28, 2020 who stated did not have enough food to eat during a meal. R4 stated asked for second helping but was told by staff the facility did not have enough food to offer a second helping. The resident mentioned in the complaint (R1) was interviewed on 6/25/2020 at 4:00 pm who stated asked for second helping but staff stated could not give second helping because facility ran out of food.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited: (Refer to LIC 809-D). Exit Interview Conducted, Copy of Appeal Rights and Report issued.

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

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
05/13/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20200513134405

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:
04/12/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident is not treated fairly while in care.
INVESTIGATION FINDINGS:
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In regard to the allegation resident is not treated fairly by staff. LPA Spaeth interviewed resident (R1) mentioned in the complaint on June 25, 2020 at 4:00 pm. R1 stated staff showed favoritism to residents who have lived at facility for long time. LPA Spaeth asked for name of staff member who showed favoritism to other residents and the name of the residents who were not treated fairly. R1 stated did not remember name of person or the incident R1 stated did not remember mentioning an incident to anyone. On October 2, 2020, LPA spoke to residents, R2 at 11:45 am, R5 at 9:45 am, R7 at 2:30 pm and R8 at 3:00 pm. All residents stated facility staff treat residents fairly. Based upon LPA Spaeth interviews with R1 who could not remember the details regarding staff not treating residents fairly and based upon interviews of four residents who stated staff treat residents fairly, this allegation is unsubstantiated.
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: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20200513134405
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2021
Section Cited
CCR
87307(a)(3)
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87307 Personal Accommodations and Services (a)(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirement was not met as evidenced by:
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LPA Spaeth received a written email confirmation and photo from Administrator Designee showing the facility had an ample supply of hygiene products available for the residents.
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Based on LPA Spaeth's interviews with Residents and LPA Spaeth personal observation of hygiene supply available, the facility did not have an adequate supply of hygiene items for residents.
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Type B
04/12/2021
Section Cited
CCR
87468.2(5)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (5) To be served food of the quality and quantity necessary to meet their nutritional needs. This requirement was not met as evidenced by:
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LPA Spaeth completed a FaceTime virtual tour of the facility on 9/24/2020. Staff members were weighing plate to make sure each resident received an adequate serving of food.
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Four residents were interviewed by LPA Spaeth who stated asked for second helping of food from staff members. However, four residents were told by staff second helpings were not available.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4