197609720-9-22-2020-31-AS-CHAS-BUCMG3-20201013093514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 09/22/2020
Date Signed: 09/22/2020 10:01:50 AM

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
09/16/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20200916140055

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	BROCK, FREDA		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 81	DATE:	09/22/2020
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Freda Brock		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility is charging residents lump sum assessments that are not allowed under regulation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Spaeth initiated a complaint investigation with Administrator, Freda Brock. The complaint states the facility is charging residents a lump sum assessment that is not allowed under regulations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted as a FaceTime visit with Freda Brock.

The complaint stated the facility is charging residents lump sum assessments that are not allowed under regulation. Per LPA Spaeth’s request, the corporate letter from Pegasus Senior Living dated July 20, 2020 regarding the monthly charge of $100 to offset the cost of personal protective equipment due to COVID-19 pandemic was sent to LPA on September 16, 2020.

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: 09/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020

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-20200916140055

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: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE	FACILITY NUMBER: 197609720
	VISIT DATE: 09/22/2020

NARRATIVE

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On September 17, 2020, LPA received a copy of the letter from Pegasus Senior Living dated September 17, 2020 stating the additional cost was retracted. LPA Spaeth spoke to Administrator on September 18, 2020 at 3:00 pm regarding the letter. Administrator stated the September 17, 2020 letter was sent to all residents. LPA Spaeth received email from Complainant on September 21, 2020 at 5:13 pm, stating Complainant had received retraction letter from Pegasus Senior Living.

Based upon LPA’s interviews with the Complainant and the Administrator, this allegation is unsubstantiated. Exit interview was conducted. A copy of the report was emailed to Administrator requesting Administrator’s signature.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020

LIC9099 (FAS) - (06/04)

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