<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 03/24/2022
Date Signed: 08/15/2022 07:18:10 PM


Document Has Been Signed on 08/15/2022 07:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:AUTUMN ROBERTS RODRIGUEZFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 80DATE:
03/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Andrea GutierrezTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Spaeth conducted an unannounced case management visit regarding an incident report that was sent to CCL on March 22, 2022. LPA was greeted by a staff member (S3) and LPA explained the purpose of LPA's visit. LPA interviewed the Health & Wellness Director and staff member (S1) from 2:35 pm until 3:00 pm. LPA was greeted by the Business Office Manager at 3:10 pm and LPA interviewed the Manager from 3:15 pm until 3:40 pm.

The incident report stated the Health & Wellness Director received a report stating a staff member (S1) had personally witnessed another staff member (S2) speaking unkindly to three residents. S1 also reported a resident had stated to S1 the resident's personal rights were violated. Upon receiving this report, the Health & Wellness Director immediately began an investigation and requested S2 to end S2's work day due to the investigation.

At 2:35 pm, LPA spoke to S1 who confirmed witnessed the incidents. During LPA's interview of the Health & Wellness Director, the Director stated a full internal investigation was conducted and S2 was terminated. At 3;15 pm, the Business Office Manager had confirmed staff members had spoken to the three residents informing them the staff member no longer worked for the facility. The Business Office Manager also confirmed the residents were comfortable with the outcome of the investigation.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to the Business Office Manager.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1