197609720-6-2-2021-31-AS-MVAO-C4GM3V-20210630091545

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 04/09/2021
Date Signed: 06/02/2021 04:06:56 PM

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
09/29/2020 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20200929085827

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: 69	DATE:	04/09/2021
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Andrea Gutierrez, Business Office Manager		TIME COMPLETED:	10:38 AM

ALLEGATION(S):

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Facility has roaches.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit to deliver the finding on the above allegation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today's visit was conducted telephonically with Andrea Gutierrez, Business Office Manager.
Allegation #1: Facility has roaches. To investigate this allegation, LPA conducted a physical tour of the facility at 3:32pm on 10/05/20. During the visit, LPA did not observe any roaches or droppings. On 10/05/20, facility residents were interviewed at 3:45pm and many indicated that they have not seen roaches in their apartment or inside of the facility. Staff was interviewed at 3:40pm and they indicated that they had not seen roaches in the facility. In addition, a review of the pest contol records revealed that the facility is fumigated every month.
Based on the observation, interviews, and record review, there is no relevant information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

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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