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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609110
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:07:37 PM

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
12/04/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20201204125310
FACILITY NAME:AV RESIDENTIALFACILITY NUMBER:
197609110
ADMINISTRATOR:BOLTON, SACHAFACILITY TYPE:
735
ADDRESS:638 EAST PILLSBURY STREETTELEPHONE:
(661) 941-8175
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 6DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sacha BoltonTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is in disrepair; electrical outlets are not working in the dining room, kitchen, and garage.
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit to the facility and met at the front door by caregiver, Debbie Smith (S1). At 11:30 am LPA checked the electrical outlets in the dining room and kitchen. Both locations had outlet that were not working. LPA Spaeth and S1 went to the garage and observed a extension chord was used for operating the washing machine and the extension chord that was used blocked a part of the exit to the garage. Therefore the allegation stating facility is in disrepair; electrical outlets are not working in the dining room, kitchen, and garage is substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

Exit inteview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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 3
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
12/04/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20201204125310

FACILITY NAME:AV RESIDENTIALFACILITY NUMBER:
197609110
ADMINISTRATOR:BOLTON, SACHAFACILITY TYPE:
735
ADDRESS:638 EAST PILLSBURY STREETTELEPHONE:
(661) 941-8175
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sacha BoltonTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is in disrepair - resident room #2 had a ceiling leak.
Facility is in disrepair - the heat does not work
Administrator is not giving residents their allowance
Residents were not served a Thanksgiving meal.
INVESTIGATION FINDINGS:
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LPA Spaeth spoke to Administrator, Debbie Smith (S1) and three residents who stated the leak had been repaired. LPA received a copy of the receipt for the repairwork. On December 9, 2021 LPA observed the ceiling was repaired. The allegation stating resident room #2 had a ceiling leak is unsubstantiated.
LPA Spaeth observed the temperature in the facility on December 13, 2021 was 72 degrees and interviewed four residents who stated the facility temperature was comfortable. Therefore, the allegation, the heat does not work is unsubstantiated.
LPA Spaeth spoke to four residents on 12/09/2021 who stated a Thanksgiving meal was served years 2019, 2020, and 2021. Administrator confirmed purchased the Thanksgiving food. Therefore the allegation residents were not served a Thanksgiving meal is unsubtantiated. Also, Administrator Sacha Bolton confirmed on 12/09/2021 she been administrator since 2018 and confirmed Frank Defabiis has not been the Administrator.
Administrator oonfirmed at 12:00 pm today that the facility does not handle P&I & LPA observed Admissions Agreement for residents states the facility does not handle P&I. Therefore the allegation Administrator is not giving residents their allowance is unsubstantied.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20201204125310
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: AV RESIDENTIAL
FACILITY NUMBER: 197609110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2021
Section Cited
CCR
85088(d)
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85088(c) Fixtures, Furniture, Equipment and Supplies - (d) If the facility operates, its own laundry, necessary supplies shall be available and equipment shall be maintained in good repair. This requirement is not met as evidenced by:
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Administrator stated repairman is scheduled to repair the outlets as of December 22, 2021. Administrator has been instructed to send a copy of the receipt to LPA Spaeth.
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Based upon LPA's tour of the facility, the electrical outlets in the dining room, kitchen, and the garage were not working. At 11:30 am, LPA observed the outlets were not working.
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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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3