197609067-4-2-2021-31-AS-RRAZ-CHLW27-20220824165353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609067
Report Date: 04/02/2021
Date Signed: 04/02/2021 10:50:51 AM

Substantiated

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
03/19/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20200319123502

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: 152	DATE:	04/02/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Naira Kostandyan		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Lack of supervision resulting in resident missing from facility.

INVESTIGATION FINDINGS:

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LPA Spaeth spoke to Administrator Designee, Jon Dipaling at 10:30 am regarding the findings of above-mentioned complaint. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint findings were conducted as a telephone visit.

LPA Spaeth conducted a thorough investigation and has confirmed the following evidence regarding Complaint 31-AS-20200319123502. The Los Angeles County Sheriff’s Department in Lancaster received a call from Antelope Valley Retirement Villa on March 18, 2020 stating resident was missing. It was reported resident was last seen by staff at 1200 hours but the facility staff called the Lancaster Sheriff Station at 2258 hours to report the resident as missing. Officer Landgren conducted investigation and found video surveillance which showed missing resident walking out the front door of the facility at 0854 hours.

Substantiated

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: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

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-20200319123502

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: 04/02/2021

NARRATIVE

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LPA Spaeth interviewed two staff members who worked the night of March 18, 2020. At 7:00 pm, staff members conducted nightly room check at 7:00 pm. Staff members confirmed knocked on missing resident’s door. Missing resident’s roommate did not open the door but stated, “I am here.” Both staff members assumed missing resident was in the room. At 10:00 pm, staff member realized missing resident did not answer the knock. Both staff members went to missing resident’s door, knocked and asked roommate to open door. Staff members checked entire room and discovered missing resident was not in room. Roommate stated did not remember when missing resident left room that day. Both staff members checked entire facility for missing resident. Staff manager was contacted and staff manager called Sheriff’s Department at 10:00 pm. Staff member working that evening searched the neighborhood but could not find missing resident. Facility staff discovered missing resident was hospitalized at Palmdale Regional Center in Palmdale, California. Facility staff did not know how missing resident ended up in Palmdale but resident returned to the facility on 3/19/2020. The discharge papers from Palmdale Regional center stated resident had been dizzy and confused.

LPA Spaeth spoke to missing resident and asked if remembered what happened on March 18, 2020. Missing resident stated remembered feeling dizzy but remembered left facility that morning to buy items needed at a convenient store. Missing resident does not remember what happened after entering the store. LPA received a copy of the Physician’s assessment which stated resident is able to leave facility.

LPA Spaeth spoke to Administrator Designee regarding the incident. Dipaling stated since the incident occurred, facility has made sure there are three caregivers in the evening. One caregiver is designated as the Gate Keeper. This staff member is to monitor the front entrance and monitor all cameras of the facility. The other two caregivers are to make sure all residents are in room at designated time. Dipaling also stated there is a "white board" and Administrator Designee has instructed caregivers to write down resident updates for that day. When caregiver leave shift, the caregiver will provide update to the caregiver who is taking place of caregiver leaving the facility. Dipaling stated this procedure is working and there has been no issues since implemented this new procedure. Dipaling stated staff members who work evening shift are required to monitor the video surveillance cameras.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200319123502

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: 04/02/2021

NARRATIVE

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Also, Dipaling stated the facility replaced front door with a new secure entrance. Dipaling stated the old door had a hinge lock. This type of door was easily assessable for residents leaving the facility without the administrative staff aware of someone leaving through the front door. Dipaling stated the new door has a magnetic lock which is controlled by staff within the office.

In regard to the allegation that the lack of Licensee supervision resulted in resident missing from the facility, Licensee failed to determine resident had been missing from the facility based on staff members’ 7;00 pm room check. Staff members stated did not realize resident was missing until 10:00 pm on 3/18/2020. Based on the information obtained the allegation is substantiated at this time. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cites. (Refer to LIC 809-D) Exit Interview conducted, copy of appeals rights and report issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20200319123502

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: 04/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/02/2021 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	Health and Safety Code Section 1569.2(c) "Care & Supervision" the facility assumes responsibility provides..ongoing assistance with daily living without which the resident's..safety or welfare would be endangered. This requirement	1 2 3 4 5 6 7	Facility staff discovered missing resident was hospitalized at Palmdale Regional Center in Palmdale, California. Resident returned to the facility on March 19, 2020. Administrator Designee implemented a plan to make sure this would not occur again. Administrator Designee also trained all staff and all staff fully implemented the plan.
	8 9 10 11 12 13 14	was not met as evidenced by: Based on staff and resident interviews revealed that resident left the facility without staff being aware resident left. Staff were not aware resident had left until after 10:00 pm the evening of March 18, 2020.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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 Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

LIC9099 (FAS) - (06/04)

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