197609720-5-10-2022-31-AS-CHAS-CELVUZ-20220520164535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 04/21/2022
Date Signed: 05/10/2022 11:34:35 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
02/18/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20210218115011

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:	04/21/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Mindy Mendoza-Perry		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are not meeting a resident's hygiene needs.
Staff did not ensure a resident was provided with an appropriate amount of fluids while in care
Staff did not meeting a resident's incontinence needs
Staff mishandled a resident's medications while in care
Staff did not treat resident's wound.
Resident's bill was incorrect

INVESTIGATION FINDINGS:

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LPA Spaeth arrived to the facility and was greeted by the Administrator M. Mendoza-Perry. LPA stated the purpose of the visit was to complete the investigation. LPA explained the allegations to Administrator, which are also listed above.

In regard to the allegation, Staff are not meeting a resident's hygiene needs, LPA Spaeth interviewed eight residents from 10:00 am until 11:00 am who receive shower assistance. The complainant explained R1 was not receiving assistance with showering needs. LPA observed R1's Physician's Report for RCFE which states R1 needs assistance with bathing. LPA interviewed R1 on 6/06/2021 who stated had received showers. At 5:15 pm, LPA spoke to Med Tech (S1) who stated all showers are documented. LPA observed seven resident files from 5:00 pm until 5:15 pm which contained shower schedule sheets, which residents sign when received shower. LPA also spoke to five residents who stated the showering procedures have improved. Theerefor this allegation is unsbustantied.

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: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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-20210218115011

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: 04/21/2022

NARRATIVE

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The allegation, Staff did not ensure a resident was provided with an appropriate amount of fluids while in care. LPA interviewed R1 on 6/06/2021. R1 stated received the fluids needed and does not remember was sick during the month of January, 2021. LPA interviewed nine residents from 10:00 am until 12:00 noon who stated receive appropriate amount of fluids while in care. This allegation is unsbustantiated

The allegation, Staff members worked at the facility when diagnosed with COVID-19. LPA spoke to Office Manager today at 3:15 pm who stated there were no staff members who worked ill during the month of January, 2021. This allegation is unsubstantiated.

The allegation, staff did not meet a resident's incontinence needs. During LPA's interview of R1, resident stated there has been no issues and stated staff have been assisting R1 when needing assistance to the restroom. LPA interviewed nine residents as of today who stated staff have answered residents' request for any incontinent issues and the wait time has only been fifteen minutes. This allegation is unsubstantiated.

In regard to staff mishandled a resident's medications while in care. LPA received R1's facility progress notes which states resident self-administer's own medications and family member was ordering medications for resident. This allegation is unsubstantiated.

The allegation, resident had a wound untreated, LPA observed R1's progress notes during the month of March, 2021 that states staff treated the wound. This allegation is unsubstantiated.

Also, the allegation which states resident's bill was incorrect. LPA received a copy R1' bill from the office manager which indicates the bill was corrected. This allegation is unsubstantiated.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC9099 (FAS) - (06/04)

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