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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 08/05/2022
Date Signed: 08/05/2022 04:01:32 PM

Unfounded


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
02/23/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220223084349
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: 79DATE:
08/05/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mindy MendozaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained a stage 4 pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced complaint visit & met with Mindy Mendoza. LPA explained the complaint alleged Resident #1 (R1) sustained a stage 4 pressure injury while in care. The complaint investigation was conducted by Investigations Branch (IB) Investigator Jose Santana. The complaint stated R1 developed a stage 4 pressure injury while in care and this resulted from facility neglect. The resident (R1) has been living at the facility since July 26, 2017 and was diagnosed with cellulitis on the buttocks as of August 15, 2017. On April 21, 2020, a home health agency noted a stage 1 pressure injury was located on S1’s sacrum. A diaper rash was noted as of October 15, 2021 on R1’s buttock. The rash was a result of a fungal infection and the redness on the buttock was noted as a stage 1 fungal rash. On February 8, 2022, the home health agency diagnosed the condition as a stage 2 pressure injury on the left buttock and the stage of this pressure injury was confirmed by R’1 physician on February 15, 2022. Based upon the physician’s diagnosis and the home health agency’s notations, the pressure injury progressed to a stage 2 which is not a prohibited condition. The allegation, R1 developed a stage 4 pressure injury while in care is therefore unfounded.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
02/23/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220223084349

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: DATE:
08/05/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident was denied access to home healthcare services



INVESTIGATION FINDINGS:
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In regard to the allegation, resident was denied access to home healthcare services, Investigator Santana also conducted the investigation regarding this allegation. R1 alleged that the home health care agency was denied access to the facility due to the Omicron surge. The home health agency’s communication records confirmed that nurses were unable to enter the facility without proof of negative COVID results. This is in direct violation of PIN 24-04-ASC. This PIN grants an exemption from COVID testing to, among others, home health personnel. The facility concierge (S1) confirmed the facility’s policy of denying access to anyone who could not provide proof of a negative COVID test within specific time parameters and (S1) acknowledged to having turned home health providers away. The result of the facility’s failure to apply the PIN’s vaccination and testing exception to home health workers was that R1 did not receive wound care treatment between January 18, 2020 and February 4, 2020. The pressure injury progressed during that time from a stage 1 to a stage 2. Based on the information obtained, this allegation is deemed Substantiated. This allegation is cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted,



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
02/23/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220223084349

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: 79DATE:
08/05/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mindy MendozaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident's special diet is not being met
Staff do not communicate with resident's authorized person regarding care
Staff has not provided resident laundry services
Staff has not kept resident's room clean


INVESTIGATION FINDINGS:
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During LPA's visit, LPA interviewed eight residents who have special dietary needs. All eight residents stated the dining room staff provide meals based upon dietary needs. The dining room supervisor stated each resident who has aspecial dietary needs are given food options and portion size options. The allegation which states resident's spcial diet is not being met is unsubstantiated. In regard to staff do not communicate with resident's authorized person regarding care is unsubtantiated. LPA asked Complainant to provide names, dates, and details of these incidents. Complainant could not remember the details.

LPA interviewed twelve residents who stated staff provide laundry services and the residents do not have any issues regarding this service. This allegation is unsubstantiated. Also, the same twelve residents stated cleaning staff have provided cleaning services and residents are satisfied with the service provided. This allegation is unsubstantiated. Exit interview was conducted, appeal rights discussed, and a copy of the report was given to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220223084349
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: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
8768.1(a)(16)
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8768.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement was not met as evidenced by:
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Administrator will review the screening process for guests based on PIN 24-04-ASC.
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Based on interviews of home health agency's staff and the facility staff member, the resident was denied access to home healthcare services. This poses an immediate health and safety risk to residents in care.
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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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4