197609720-4-15-2022-31-AS-CHAS-CDXVTL-20220429164320

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:52:18 PM

Unsubstantiated

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
06/22/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20210622103310

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: 84	DATE:	04/15/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Mindy Mendoza-Perry		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff not responding to resident's call light in a timely manner.
Food is not of quality.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Melissa Spaeth conducted an unannounced visit regarding a complaint which states staff not responding to resident's call light in a timely manner and food is not of quality. Upon arrival LPA's temperature was recorded and LPA answered the COVID-19 symptom questinos.

LPA was greeted by the Administrator and LPA stated the purpose of the visit was to continue the investigation of the complaint and report LPA's findings. LPA interviewed residents from 11:30 am until 1:00 pm. LPA conducted a physical tour of the facility from 1:10 pm until 1:25 pm. LPA did not observe any health or safety issues.

Staff not responding to resident's call light in a timely manner - LPA interviewed fourteen (14) residents and asked if any residents had to wait longer than twenty minutes after pushing the pendant. All fourteen residents stated had not have to wait more than twenty minutes for assistance. Ten of the fourteen residents stated the response time has improved.

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: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

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-20210622103310

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: 04/15/2022

NARRATIVE

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It was alleged that the facility is short staffed. However, LPA Spaeth spoke to Administrator who stated there are on an average four caregivers covering the day shift along with two med technicians. There are three caregivers and two med technicians covering the evening shift and one to two caregivers and one med technician covering the night shift. The Administrator stated there has not been any complaints regarding of
response time for the caregivers. LPA also interviewed two staff members who work with residents who stated there has not been any complaints from residents regarding response time of their response to residents. Also LPA Spaeth received a copy of the staff schedule which confirms there are an adequate number of staff members covering each shift. Therefore, this allegation is unsubstantiated.

Food is not of quality - LPA Spaeth interviewed ten (10) residents regarding the quality of the food. The ten residents stated the quality of the food has improved and hthe caregiver schedule which confirms there are an adequate number of caregivers during each shift. . Therefore, this allegation is unsubstantiated. ave not had any issues. Three residents stated there are times do not prefer what is on the menu but kitchen staff offer other options. All ten residents confirmed that the facility provides second helpings tor all residents. Therefore this allegation is unsubstantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC9099 (FAS) - (06/04)

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