197609720-4-22-2022-31-AS-CHAS-CE4TNZ-20220504145333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 04/22/2022
Date Signed: 04/22/2022 04:58:06 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
08/09/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20210809140504

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: 83	DATE:	04/22/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mindy Mendoza-Perry		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff failed to provide a safe environment for the residents.

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unnanounced visit to the facility and was greeted by Administrator, M. Mendoza-Perry. LPA stated the purpose of the visit was to conclude the investigation of the complaint which states illegal eviction, staff failed to provide a safe environment for the residents, staff failed to meet residents' needs, and facility failed to issue a refund.
In regard to the allegation, staff failed to provide a safe environment for the residents, LPA Spaeth interviewed the complainant on 8/12/2021. Complainant stated received a call from facility staff on July 22, 2021 stating resident (R1) had left the facility through a fire exit door that had been left open by construction workers. LPA interviewed staff member (S1) on 8/12/2021 who found R1 outside one block from the facility. S1 stated had gone to R1's room for med. distribution but found R1 was gone. S1 then found door was open and should have been closed. LPA viewed Physician's Report which states resident should not leave the facility without assistance. Based on the information obtained this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal rights were discussed, exit interview conducted, and a copy of the report was given to the Administrator.

Substantiated

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: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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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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
08/09/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20210809140504

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:	DATE:	04/22/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mindy Mendoza-Perry		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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9

Illegal eviction
Staff failed to meet residents' needs
Facility failed to issue a refund

INVESTIGATION FINDINGS:

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The allegation, regarding an illegal eviction, the Complainant stated facility's Office Manager stated to the Complainant that the facility would be evicting R1. On 8/12/2021, LPA interviewed Office Manager who stated did not verbally state to Complainant R1 would be evicted. Officer Manager stated the facility eviction policy requires a written eviction notice be issued to the resident. Officer Manager stated an eviction notice was not issued. LPA reviewed R1's file on 08/12/2021 but not find an eviction notice. Therefore, this allegation is unsubstantiated. The allegation, staff failed to meet residents' needs, the complainant stated R1 would request staff members' assistance but staff would not report to R1's room to assist R1. On 8/12/2021, LPA interviewed two staff members who assisted R1 who stated always responded to R1's call within fifteen minutes. LPA also interviewed nine residents on 4/21/2022 who stated caregivers do not ignore resident’s call for assistance. All nine residents also stated wait time is only approximately fifteen minutes. Therefore, this allegation is unsubstantiated. The allegation stating facility failed to issue a refund was also investigated by LPA Spaeth. The Complainant stated was unhappy with the service provided and stated R1 lived in the facility for two months. Complainant requested entire two month’s rent that was paid to the facility be returned to the Complainant. LPA Spaeth received resident ledger report from the Officer Manager as of 4/21/2022 which states the amount the facility billed the resident and the amount paid by the resident. The report states Complainant was invoiced for $10,690.00 for the two month rental charge and the facility refunded $6,325.00 to the Complainant. The facility also refunded the resident care fee, rent for August 1, 2021 through August 9, 2021, and the community fee which totaled $7,666.88. This allegation is unsubstantiated.

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: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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-20210809140504

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/28/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a)In addition to the rights listed in …, residents in.. care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers,	1 2 3 4 5 6 7	The staff will ensure when outside vendors come to complete work on the faciliy, the vendors will be instructed to keep fire exit doors closed when not in the immediate vacinity. Caregivers will be instructed to regularly check fire exit doors when vendors are on the premises. Administrator will educate staff
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based upon LPA's interviews of the staff members, caregivers were not aware the resident had left the building without an escort, which is an immediate health and safety risk to 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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC9099 (FAS) - (06/04)

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