197609112-7-14-2023-31-AS-EMIR-D7FPJW-20240723112213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609112
Report Date: 07/14/2023
Date Signed: 07/14/2023 11:19:26 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
07/07/2023 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230707092651

FACILITY NAME:	AV RESIDENTIAL III		FACILITY NUMBER:	197609112
ADMINISTRATOR:	DAWSON, KRISTI		FACILITY TYPE:	735
ADDRESS:	1160 WEST AVE J5		TELEPHONE:	(661) 941-8175
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	6	CENSUS: 6	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Linda Fairbanks (Lead Staff)		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility has a bed bug infestation.

INVESTIGATION FINDINGS:

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On 07/14/22 Licensing Program Analysts (LPA) Evelin Rios conducted an unannounced complaint investigation visit. Upon arrival LPA was met by staff Linda Fairbanks and the purpose of the visit was explained. Linda contacted administrator Sasha Bolton and LPA explained the purpose of the visit via telephone. Entrance interview conducted.

Allegation: Facility has a bed bug infestation.
It is alleged that the facility has bed bugs. At approximately 9:30 a.m LPA Evelin Rios conducted physical plant tour of the facility. LPA conducted interviews with staff and residents. Interview with the administrator confirmed they are aware the facility has bedbugs. Administrator stated they are in the process of handling it right now. According to the administrator the facility was notified a week ago from today that there are bedbugs. Since finding out the facility began to remove items from residents room that were observed to have bedbugs. Mattresses were treated outdoors and resident's laundry was taken to laundry mat to be washed and treated. (LIC9099-C Continued on next page)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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

Control Number 31-AS-20230707092651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AV RESIDENTIAL III	FACILITY NUMBER: 197609112
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/15/2023 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.(1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to send a copy of the invoice of pest control treatments on or before the POC date.
	8 9 10 11 12 13 14	Based on LPA observation and interview, Licensee failed to ensure that the facility is free of pests such as bedbugs, which poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230707092651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AV RESIDENTIAL III	FACILITY NUMBER: 197609112
	VISIT DATE: 07/14/2023

NARRATIVE

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Furthermore, the administrator states the facility has been treated before for bedbugs. The facility will be removing the carpet and replacing it with hard floors. A contracted exterminator will be treating the facility again. LPA requested a copy of the exterminators invoice. Linda stated they were not present when the facility was treated but had heard they sprayed the facility and used a bug bomb. Interviews with (4) out of (6) residents revealed they do have bed bugs on their beds. Based on the information obtained through interviews, observation, and record review, it was concluded that the facility is infested with bedbugs and although immediate measures were taken by the facility to resolve the issue the recurrence of bedbugs presents a health and safety concern for the residents in care. Therefore, based on interviews and observation, this allegation is deemed Substantiated at this time.

Deficiency cited, Exit interview conducted, copy of report and appeal rights issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

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