197609067-8-5-2021-31-AS-DPEA-C5QN5F-20210809100924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 08/05/2021
Date Signed: 08/05/2021 04:17:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2019 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 31-AS-20190109081553

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: 0	DATE:	08/05/2021
		UNANNOUNCED	TIME BEGAN:	02:36 PM
MET WITH:	Marcel Filart, MD		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in resident being assaulted by another resident.
Failure to seek timely medical attention

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent telephonic complaint visit for the purpose of deliver findings for the above allegations. The initial visit was conducted on 01/10/2019 by LPAs Gary Tan and Brian Balisi. On today’s telephonic visit, LPA Lopez spoke with Licensee Representative Marcel Filart, MD and explained the reason for the telephone call. Dr. Filart requested the LPA send him the report via mail and declined to review and discuss the report findings over the telephone.

On 01/09/2019, the Department received a complaint in which it was alleged that a lack of supervision resulted in Resident 1 (R1) being physically (and sexually) assaulted by another resident; and, that the facility staff failed to seek timely medical attention for R1. The complaint was referred to Community Care Licensing’s Investigations Branch (IB) and assigned to Investigator, Lorraine Patterson.

Report continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 31-AS-20190109081553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ANTELOPE VALLEY RETIREMENT VILLA	FACILITY NUMBER: 197609067
	VISIT DATE: 08/05/2021

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

On 01/10/2019, between 8:45 a.m. and 3:00 p.m., LPAs Gary Tan and Brian Balisi conducted the initial complaint visit and interviewed Naira Kostandyan, Administrator, Glen Arnold, Administrator Designee and facility staff. In addition, the LPAs reviewed and obtained copies of pertinent documents relevant to the investigation. On 01/18/2019, between 9:00 a.m. and 3:00 p.m., LPAs Gary Tan and Brian Balisi conducted a subsequent unannounced complaint visit to review facility records, obtain copies of pertinent documents relevant to the investigation, reviewed camera footage and conducted additional staff interviews.

Investigator Patterson conducted an interview with the reporting party on 02/06/2019 at approximately 11:50 a.m. Interviews were conducted on 03/05/2019 with the Administrator, staff and R1 from approximately 12:30 p.m. to 2:50 p.m. Additional interviews were conducted with the administrator designee on 03/13/2019 at approximately 10:00 a.m. and the residents on 03/14/2019 from approximately 11:30 a.m. to 1:00 p.m. The staff were interviewed at approximately 2:15 p.m. on 3/14/2021, at approximately 8:00 a.m. on 03/15/2019 and from approximately 3:20 p.m. to approximately 3:37 p.m. on 03/18/2019. Facility records, medical and police reports were also obtained and reviewed.

On 01/04/2019, caregivers on the a.m. shift and a housekeeper witnessed R1 in R1’s bedroom with a bloody nose and a red eye. Blood was also observed on R1’s bedsheets, underwear, pants and the backside of R1’s clothing. R1 admitted R1 was hit in the face by another resident after refusing to have sex with the other resident. When R1’s clinician came to the facility to visit R1 on 01/04/19, the clinician noticed that R1 was in distress and had blood on R1’s upper lip and nostril area. Facility staff told the clinician that R1 may have been sexually and physically assaulted, that R1 reported that R4 had hit R1 in the face. The facility camera footage from 01/04/2019 did not provide any conclusive evidence of the incident due to the angle of the camera, though it did show that R3 entered R1’s room at 1:10 a.m. on 1/4/2019. However, the camera footage did not depict when R3 left the room.

On 01/07/2019, the clinician followed up with the facility staff regarding R1 and was told that the Sheriff’s Department never sent anyone out to take the report. Staff also told the clinician that R1 had not been taken to the hospital for a medical exam because the facility was waiting for the Sheriff’s Department staff to arrive and tell them what to do. The clinician then called the Sheriff’s Department to request that an incident report be taken.

Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 31-AS-20190109081553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ANTELOPE VALLEY RETIREMENT VILLA	FACILITY NUMBER: 197609067
	VISIT DATE: 08/05/2021

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

The deputy’s incident report dated 01/08/2019 summarized that R1 stated R4 woke R1 up from R1’s sleep on 01/04/2019 and told R1 that if R1 did not have sexual intercourse with R4, R4 would physically assault R1. R1 reported that R1 did not want to have sexual intercourse with R4 and as a result R1 was hit in the face multiple times by R4 and then was sexually assaulted for approximately three hours. R4 informed R1 that if R1 told anyone about the physical and sexual assault, R1 would regret it. At 1:10 a.m. on 01/04/2019, the facility surveillance footage showed that R3 walked into R1’s bedroom; however, due to the security system controls, there was no way of observing how long R3 was inside R1’s bedroom. R1 denied that R3 sexually assaulted R1. There were no additional video surveillance or witnesses to the incident. Both R4 and R3 denied any contact with R1 on 01/04/2019.

Regarding the subsequent incident, the Unusual Incident/Injury Report dated 01/31/2019, revealed that R1 was found at 11:25 a.m. with scratches on R1’s back and anal area. The Administrator Designee was informed right away. On 02/01/2019, at approximately 5:00 p.m., the Administrator Designee told R1’s clinician that R1 was taken to the emergency room for “visible markings on [R1’s] back [injuries]”. The clinician asked the Administrator Designee what the facility was doing to protect R1 from these assaults. The clinician was told that R1 was moved from the second floor to the first floor and placed in a bedroom that is closer to the administration area.

The deputy’s report, dated 02/01/2019, summarized that the Sheriff’s Department responded to the Hospital regarding a sexual assault. R1 reported that R1 was sexually assaulted by R4 on 01/28/2019, from approximately 3:00 p.m. to 6:00 p.m. Deputies attempted to contact R1’s roommate R2, but R2 did not answer the door. The facility staff advised the deputies that R2 was likely sleeping during the assaults, due to R2’s medication. The report noted that due to the conflicting and inconsistent statements made, there was no determination if a crime had occurred at the end of the investigation.

IB Investigator Patterson did interview R2, who stated that R2 has not witnessed any abuse on any resident or facility staff since R2 arrived at the facility; and, if R2 had observed abuse, R2 would have stopped it or at least reported it. However, interviews revealed that R2 could have been a suspect as well.

Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 31-AS-20190109081553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ANTELOPE VALLEY RETIREMENT VILLA	FACILITY NUMBER: 197609067
	VISIT DATE: 08/05/2021

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

According to the medical records, R1 was brought into the Hospital on 02/01/2019 at around 3:00 p.m. R1 complained of pain in the rectal area and stated the injury occurred at the Antelope Valley Retirement Villa. R1 stated that R1 did not know the assailant. The Forensic Sexual Assault Examination reported multiple abrasions to the right side and middle of R1’s back, around the anal opening and on the bottom of the scrotum; redness to penis, including right and left shaft and opening of the anal canal. It was further noted that although the examination was completed, the findings were limited because of R1’s anxiety and lack of cooperation.

During the course of the investigation, Investigator Patterson determined that R1 was physically and sexually assaulted by another resident on 01/04/2019 and on 01/28/2019. Information obtained through documents and interviews revealed that the facility’s administration did not address the resident’s supervision, basic care and safety needs. Besides failing to monitor the facility residents, non-residents from the outside had access to both floors of the facility. There was no security detail assigned to the facility and there were a minimal number of caregivers assigned to each shift. The lack of administration’s presence/involvement, the problem with hiring/retention of caregivers, continues to attribute to an ongoing problem where the safety, security, care and supervision of the residents is compromised, lacks or goes unmet. Interviews conducted and records reviewed revealed that R1 had a history of medical and mental health concerns and had difficulties with orientation of time and place, which may be a contributing factor to unclear statements of who, when and how many times R1 was assaulted.

Based on the facts gathered, interviews held, including information, reports and documents obtained, the facility’s failure to protect R1 further resulted in R1 sustaining a second assault by another resident. There is enough evidence to support the allegation of “Lack of supervision resulting in resident being assaulted by another resident”. The allegation is therefore deemed Substantiated.

Regarding the allegation, ‘Failure to seek timely medical attention’, when the facility staff discovered that R1 was assaulted by another resident on 01/04/2019, they did not follow up with the Sheriff’s Department when the Sheriff Department’s staff did not come out to take the report. Four (4) days later, when a clinician made a visit, they contacted the Sheriff’s Department. R1 was never provided with medical attention nor taken for a medical evaluation at the local hospital. When R1 was assaulted by another individual for a second time on 01/31/2019, R1 was not taken to a hospital nor was law enforcement contacted until approximately 27 hours after the assault. Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20190109081553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ANTELOPE VALLEY RETIREMENT VILLA	FACILITY NUMBER: 197609067
	VISIT DATE: 08/05/2021

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

Based on the facts gathered, interviews held, including information, reports and documents obtained, there is enough evidence to support the allegation that the “facility did not seek timely medical attention” for R1. The allegation is therefore deemed Substantiated.

Exit interview conducted, deficiencies cited, copy of report and appeal rights will be mailed to the licensee for signature at the address he provided during the 08/05/2021 telephone call.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20190109081553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HSC 1569.312(a)(b)	1 2 3 4 5 6 7	H&S1569.312 Basic services requirements....(a) Care and supervision as defined in Section 1569.2 (e) Monitoring the activities of the residents while they are under the supervision of the facility.... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility closed effective 12/01/2020.
	8 9 10 11 12 13 14	Based on record review and interviews, the Licensee failed to ensure there was adequate supervision resulting in R1 being assaulted by another resident on 01/04/2019 and 01/31/2019, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 08/05/2021 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (a) (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical......This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility closed effective 12/01/2020.
	8 9 10 11 12 13 14	Based on record review and interviews, the Licensee failed to ensure that R1 received timely medical care on 01/04/2019 and 01/31/2019, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 6 of 6