197609720-4-23-2021-31-AS-CHAS-C4BTWU-20210625150607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 04/23/2021
Date Signed: 04/23/2021 03:42:46 PM

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
10/29/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20201029093357

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: 67	DATE:	04/23/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Cynthia Edwards		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Financial Abuse by Facility Staff.

Staff mismanaged a resident's clothing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit to deliver the findings on the above-referenced allegations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today's visit was conducted as a FaceTime visit with Cynthia Edwards, Administrator for the facility.

In regard to the allegation stating financial abuse by facility staff, LPA Spaeth interviewed the resident on 10/30/2020 at 3:00 pm and resident stated the facility had charged a care-November fee of $415.00. Resident stated did not know the reason for the charge. Resident stated spoke to Administrator and Administrator issued a new bill in which the $415.00 charge was removed from the bill. LPA Spaeth received a copy of the

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: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

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-20201029093357

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: 04/23/2021

NARRATIVE

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October 30, 2020 updated bill and observed the $415.00 had been deducted from the bill.
In regard to the allegation staff mismanaged resident's clothing, LPA Spaeth spoke to resident on 10/30/2020 at 3:00 pm regarding missing clothing. Resident stated red leather jacket was missing and resident stated staff member had stolen the jacket. LPA Spaeth asked R1 the name of the staff member who stole the jacket. R1 did not know who stole the jacket. Resident stated asked housekeeping staff member if took the jacket but staff member stated no. LPA Spaeth asked resident if resident witnessed staff member stealing R1's jacket. R1 stated no.

On November 3, 2020, LPA Spaeth received an email from Administrator, Freda Brock at 2:45 pm stating R1 had stated to Administrator that R1's jacket was missing and the color of the jacket was brown, not red. Administrator stated within the email the brown leather jacket was found by Administrator on November 3, 2020 in a box within R1's room.

LPA Spaeth spoke to lead housekeeping staff member on 4/16/2021 at 2:15 pm and asked if staff member took jacket. Staff member stated no and stated lead housekeeping staff member was asked by R1 to search R1's room for the jacket. Staff member searched R1's room while R1 was in the room but the jacket was not found. LPA Spaeth spoke to staff member who also cleans R1's room on 4/19/2021 at 2:45 pm regarding leather jacket. Staff member stated did not take the leather jacket from R1's room and never has taken clothing from any resident's room. Staff member stated R1 had not mentioned the leather jacket to R1. LPA Spaeth spoke to Administrator, Cynthia Edwards on 4/19/2021 at 3:45 pm who stated Administrator and staff member searched R1's room but did not find the leather jacket; however Administrator stated found two blouses in R1's room in which R1 thought was missing. Administrator stated R1 has left clothing in another resident's room. Administrator stated R1 has never accused staff members of stealing R1's clothing.

Based upon LPA's interviews of staff members, Administrator and the resident and upon the evidence presented to LPA, there is insufficient evidence to validate the above-mentioned allegations, therefore, at this time the complaint is deemed Unsubstantiated. Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

LIC9099 (FAS) - (06/04)

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