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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 11/18/2022
Date Signed: 11/18/2022 04:12:09 PM


Document Has Been Signed on 11/18/2022 04:12 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:MINDY MENDOZA-PERRYFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 65DATE:
11/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:MINDY MENDOZA-PERRY TIME COMPLETED:
04:15 PM
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LPA arrived to facility and conducted an unannounced visit. LPA stated the purpose of the visit was to investigate a call LPA Spaeth received regarding an incident that occurred at the facility. It was reported that on one occasion last week a call was not answered by staff after 8:00 pm and the caller was requesting entry into the facility. LPA spoke to caller today at 1:50 pm who stated on that occasion last week, the security guard opened the door for the caller and caller entered the facility.

LPA Spaeth interviewed Administrator at 2:45 pm until 3:15 pm. LPA also received a copy of the staff schedule and observed there are two to three caregivers and one medical technician working the evening shift. Administrator also stated the caregivers carry a cell phone which is connected to the facility phone number so that staff can answer any incoming calls. Administrator also stated caregivers also carry a second cell phone. The residents call that number when need assistance during the evening hours. Administrator stated has called the facility phone number at various times during the evening and the caregivers have promptly answered the phone. Also, Administrator stated caregivers' top priority is care and safety of all residents. LPA interviewed caregiver from 3:45 pm until 4:00 pm who stated a resident left the facility last week during the evening hours and returned. Caregivers were assisting the residents when a resident called. Caregiver stated the co-worker did go to the front door and opened the front door for the resident.

There are no deficiencies at this time. Exit interview was conducted and a copy of the report was given to the Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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