197609720-5-3-2022-31-AS-CHAS-CECT8K-20220512143028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 04/28/2022
Date Signed: 05/03/2022 07:45:26 AM

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
02/09/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220209114031

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	AUTUMN ROBERTS RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 84	DATE:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mindy Mendoza-Perry		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not answering call bells in a timely manner,
Residents are not receiving medications timely
Dining room tables are not being cleaned properly
Staff did not attend to residents medical needs in a timely manner

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 staff are not answering call bells in a timely manner, residents are not receiving medications in a timely manner, dining room tables are not being cleaned properly and staff did not attend to residents' medical needs in a timely manner.

LPA interviewed staff member S1 from 9:50 am until 10:20 am. LPA interview dining staff from 10:20 am until 11:10 am. LPA interviewed fifteen residents from 11:10 am until 12:00 pm and 2:00 pm until 2:45 pm. LPA reviewed residents' records from 3:10 pm until 3:25 pm.

In regard to the allegation, staff are not answering call bells in a timely manner, LPA interviewed nine residents who stated staff answer call button or pendant within fifteen minutes. Four residents stated there are additional caregivers working each shift and the response time has improved. Therefore this allegation is unsustantiated.

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: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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-20220209114031

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: 04/28/2022

NARRATIVE

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In regard to the allegation, residents are not receiving medications in a timely manner, LPA interviewed nine residents who stated receive medications on time each day. All nine residents stated have not missed any doses of medication and the care of the medical technicians has greatly improved. Therefore this allegation is unsubstantiated.

The allegation, dining room tables are not being cleaned properly is also unsubstantiated. LPA Spaeth interviewed nine residents who stated the tables, placemats, and silverware are clean during each meal. LPA interviewed three dining room staff who stated the tables, placemats, and all silverware are sanitized after each meal. At 11:45 am, LPA observed two dining room staff members who were sanitizing the table and placemats before the noon meal. LPA observed the staff were wearing masks and gloves.

In regard to the allegation, staff did not attend to residents' medical needs in a timely manner, LPA Spaeth interviewed nine residents who stated when need any kind of assistance such as blood pressure check, wound check, or other assistance, the caregivers and medical technicians have assisted residents. During LPA visit, LPA heard staff member using the facility intercom system stating a blood pressure check was available for all residents. Therefore this allegation is unsubstantiated.

Exit interview was 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: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

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