197609720-1-11-2023-31-AS-MSPH-CMZ2LS-20230111162959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 01/11/2023
Date Signed: 01/11/2023 04:30:23 PM

Document Has Been Signed on 01/11/2023 04:30 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, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	MINDY MENDOZA-PERRY		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 78	DATE:	01/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mindy Mendoza-Perry		TIME COMPLETED:	11:45 AM

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LPA Spaeth conducted an unannounced visit and was greeted by Administrator. Upon arriving to the facility, LPA observed the COVID-19 signs along with the sign in station for guests to sign in and complete the COVID-19 questionnaire. LPA stated the purpose of the visit was to conduct an annual visit. Administrator confirmed there are currently 78 residents in the facility. LPA Spaeth and Administrator toured the facility at 10:00 am until 10:30 am.

Kitchen/Dining Hall – Upon entering the dining hall, LPA observed three residents leaving the dining hall after eating breakfast. The residents were escorted by caregivers back to their rooms. Upon entering the kitchen LPA observed a three-day supply of perishable food along with a seven day supply of non-perishable canned goods, pasta and other food items. LPA observed the dry storage room also contained the emergency supply of food. LPA observed fire extinguishers located in the kitchen. The kitchen staff were prepping for the noon meal and were wearing masks. The staff sink for washing hands contained wash your hands sign, paper towels, hand soap, and a trash can. The kitchen was neat and clean. LPA also observed fresh fruit was available for residents to take when exiting the dining hall.

Med Tech Room – LPA observed the med tech cart was securely locked. Also the residents’ files are also safely locked in the room.

Outdoor area – LPA observed comfortable seating in the outside courtyard. LPA did not observed any safety issues when observed the area.

Residents’ Apartments – LPA observed the residents’ apartments were neat and clean. The apartments contained a bed, night stand, lamp, and a chair and/or couch.

Public Restrooms – LPA observed the public restrooms were clean and contained wash your hands sign, hand soap, paper towels, and a trash can.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/11/2023

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PPE Supplies – LPA observed a locked room which contained a six-month supply of hand sanitizer, surgical masks, N-95 masks, face masks, gloves and gowns. Administrator stated has ensured have an adequate supply in case of a future need.

Memory Care Wing- LPA observed the new memory care wing is still under construction. Administrator stated the major construction has been completed and the projected grand opening will soon take place. Upon entering the wing, LPA observed the keypad had been installed. Administrator stated the facility will provide memory care services for eighteen residents. LPA observed there are eight single rooms and five shared rooms. The rooms all contain a bathroom with a walk in shower.

Common Areas - LPA observed new carpeting and lighting had been installed throughout the walk areas on both floors.

There are no health or safety issues to report at this time and no deficiencies to report. The exit interview was conducted and a copy of the signed report was given to the Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC809 (FAS) - (06/04)

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