197609067-8-12-2022-31-AS-RRAZ-CHE4AK-20220817185606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 08/10/2022
Date Signed: 08/12/2022 02:27:40 PM

Unsubstantiated

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
09/17/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20200917140123

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:	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:			TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Residents are engaging in physical altercations
Facility staff are not providing residents with an adequate amount of time to eat their meals
Facility is in disrepair, an elevator is not operational

INVESTIGATION FINDINGS:

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LPA conducted an unannounced visit and met with Administrator. LPA stated the purpose of the visit was regarding a complaint which states: residents are engaging in physical altercations, facility staff are not providing residents with an adequate amount of time to eat their meals, and facility is in disrepair, an elevator is not operational. LPA confirmed the complaint was submitted during 2020 which was the time the facility was Antelope Valley Retirement Villa

LPA interviewed residents and staff from 10:45 am until 11:30 am. LPA reviewed resident's file from 11:30 am until 11:45 am until 11:50 am.
In regard to allegation, residents are engaging in physical altercations, LPA interviewed the Administrator Designee and three staff members regarding incidents that allegedly occurred between three named residents. The three staff members stated the three residents mentioned dd not participate in altercations. Also, LPA interviewed one of the three residents mentioned who stated did not participate in altercations with the other two residents. This allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200917140123

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: 08/10/2022

NARRATIVE

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LPA interviewed eleven residents and four staff members regarding the allegation, facility staff are not providing residents with an adequate amount of time to eat their meals. The eleven residents stated dining room staff allow residents to finish eating every meal. The residents stated feel comfortable sitting down and taking time to eat each meal. The three staff members interviewed stated dining staff do allow residents to finish meals without rushing residents. Therefore this allegation is unsubstantiated.

In regarding to the allegation, facility is in disrepair, an elevator is not operational. The Administrator Designee stated the elevator was repaired in 2020 but the repairman arrived within thirty minutes and immediately repaired the elevator. Administrator Designee stated caregivers ensured residents' needs were met and there were no incidents or issues during that time. This allegation is also unsubstantiated. LPA interviewed a staff member who was working on that day who stated the elevator was immediately repaired and there were no issues regarding the residents on that day.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC9099 (FAS) - (06/04)

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