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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 01/07/2022
Date Signed: 01/07/2022 03:38:35 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
02/21/2020 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20200221125303
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:
01/07/2022
UNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Jon Dipaling - Assistant AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident was admitted with prohibited health condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to deliver the findings for the above allegation. LPA met with Assistant Administrator Jon Dipaling and explained the reason for today's visit.

The investigation of the allegation was initiated by LPA Gary Tan. During the initial visit on 02/24/2020 at 12:03 PM, LPA Tan obtained copies of facility records relevant to the investigation and interviewed staff at 12:30 PM. Investigation Branch (IB) Investigator Phillipe Ryan Miles also conducted a separate investigation regarding the same allegation.

It was alleged that the Resident #1 (R1) was admitted at the hospital on 02/07/20 with Stage 3 pressure injury.

(continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
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-20200221125303
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: 01/07/2022
NARRATIVE
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(continued from LIC 9099)

During the course of the investigation, IB investigator Miles interviewed R1 on 03/17/2020 and R1 admitted that they were aware of having pressure injuries prior to admission to this facility. LPA's interview with the assistant administrator on 02/24/2020 revealed that although facility staff was aware of R1’s health condition, they still admitted R1 to the facility. R1 was admitted with the intent to obtain home health or hospice care services for R1 so that they could provide wound care for R1’s pressure injuries, R1 however was denied hospice and home health services due to ineligibility.

LPA’s record review conducted on 02/24/20 verified the information revealed from the interviews.

Overall investigation revealed that R1 was admitted to the facility on 12/27/2019 with unstageable pressure injuries which R1 developed prior to admission. Despite the denial of hospice and home health insurance coverage due to R1's ineligibility, the resident continued to reside in the facility with prohibited health condition until R1 was hospitalized on 02/07/20 for a medical reason unrelated to pressure injury.

Based on interviews and review of medical records it was concluded that facility admitted and retained R1 with prohibited medical condition. Therefore, the allegation is deemed substantiated at this time.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
02/21/2020 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20200221125303

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:
01/07/2022
UNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Jessica Pelaya - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to deliver the findings for the above allegation. LPA met with Assistant Administrator Jon Dipaling and exained the reason for today's visit.

Regarding the allegation that the resident was unlawfully evicted, it was alleged that Resident #1 (R1) was not accepted to the facility upon discharge from the hospital. LPA's interview with the Assistant administrator conducted on 02/24/20 at 12:45 PM revealed that R1 was not evicted. R1 was not accepted back to the facility due to prohibited health condition which required 24 hour nursing care. LPA’s record review on 02/24/2020 revealed that the R1 needed higher level of care and should had not been admitted due to R1’s prohibited health condition (Stage 3 or 4 pressure injury). Based on the information gathered during the course of the investigation, there is no pertinent information to verify the allegation. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20200221125303
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: 01/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2022
Section Cited
CCR
87615(a)(1)
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Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.

This requirement is not met as evidenced by:
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Cleared during visit. The facility closed on 12/01/2020.
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Based on the record review and interviews. Licensee did not ensure not to admit and retained a resident with prohibited health condition. This poses an immediate health and safety risk to the 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4