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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609067
Report Date: 08/05/2021
Date Signed: 08/05/2021 05:09:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: 0DATE:
08/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Marcel Filart, MDTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 31-AS-20190109081553). LPA conducted a telephonic inspection visit with Licensee Representative Marcel Filart MD at 2:36 PM. The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Dr. Filart requested the LPA send him the report via mail and declined to review and discuss the report findings over the telephone.

During the complaint investigation of complaint # 31-AS-20190109081553, the following deficiencies were observed: The Licensing Information System (LIS) Facility Personnel Report Summary, dated 01/09/2019, did not list Staff 1 (S1) on the report. S1 was working as a caregiver at the facility during January 2019 without a criminal record clearance.

On 01/04/2019 and 01/31/2019, when R1 reported that R1 was assaulted by another resident, the Administrator failed to complete and submit the form SOC341 “Report of Suspected Dependent Adult/Elder Abuse Report” to appropriate parties including Community Care Licensing, Long Term Care Ombudsman, and local law enforcement agency.

The Administrator failed to take appropriate steps to protect R1, resulting in R1 being assaulted by another resident on 01/04/2019 and 01/31/2019.

Citation issued, Immediate Civil Penalty $500 assessed, exit interview, copy of report and appeal rights will be mailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5138
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ANTELOPE VALLEY RETIREMENT VILLA
FACILITY NUMBER: 197609067
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2021
Section Cited

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87355(e)(1) Criminal Record Clearance. (e) ...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above as S1 worked as a caregiver at the facility during January 2019 without a criminal record clearance, which posed an immediate health and safety risk to residents in care.
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Type A
08/05/2021
Section Cited

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87405 (a)(1)Administrator - Qualifications and Duties. (a) If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.

This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above as the administrator failed to take appropriate steps to protect R1 resulting in R1 being assaulted by another resident on 01/04/2019 and 01/31/19 which posed an immediate safety risk to residents in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5138
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ANTELOPE VALLEY RETIREMENT VILLA
FACILITY NUMBER: 197609067
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2021
Section Cited

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87211(b) Reporting Requirements. (b) Any suspected physical abuse that results in... injury of a ...dependent adult shall be reported to local ombudsman, the... licensing agency, and the local law enforcement agency within two (2) hours as required... This requirement is not met as evidenced by:
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Based on interview and record record, the licensee failed to comply with the section cited above as the administrator failed to complete the Form SOC341 when R1 reported being assaulted which posed an immediate health and safety risk to residents in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5138
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3