197609720-1-9-2023-31-AS-RRAZ-CP96D5-20230220194229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 01/09/2023
Date Signed: 01/09/2023 05:36:18 PM

Unsubstantiated

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
12/05/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20221205133217

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: 76	DATE:	01/09/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Andrea Gutierrez		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff are not providing residents with adequate food service
Staff are not meeting residents needs
Staff are not following COVID-19 protocols
Staff did not ensure residents room are locked
Staff are not ensuring the facility is free of dust

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unannounced visit and was greeted by the receptionist. LPA answered the COVID questions and was greeted by the Business Office Manager. LPA stated the purpose of the visit was to conduct an investigation regarding the allegations: staff are not providing residents with adequate food service, staff are not meeting residents needs, staff are not following COVID-19 protocols, staff did not ensure residents room is is not in disrepair; and staff are not ensuring the facility is free of dust. LPA conducted a tour of the facility at 10:30 pm until 10: 55 am but did not observed any health or safety issues. LPA interviewed thirteen residents at 12:30 pm until 2:00 pm. LPA and maintenance staff member checked eight residents' doors at 2:00 pm until 3:00 pm.

It was reported that residents were not receiving meals in a timely manner and not meeting residents' needs during the December, 2021 COVID-19 outbreak. LPA interviewed thirteen residents. Twelve out of the thirteen residents stated staff delivered meals to residents' room during the pandemic and the meals were delivered on time. Residents also confirmed that staff were meeting residents' needs during the pangemic

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

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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Control Number 31-AS-20221205133217

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
	VISIT DATE: 01/09/2023

NARRATIVE

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and stated staff checked on each resident on a daiy basis, recorded temperatures, and asked if residents were experiencing symptoms. The allegations, staff are not providing residents with adequate food service, and staff are not meeting residents' needs are unsubstantiated.

During residents' interviews, the thirteen residents stated administrative staff had daily communicated to the residents regarding the facility construction of the memory care wing. Twelve of the thirteen residents
stated had no issues with dust during the construction and did not experience any breathing or health issues during that time. The thirteen residents also stated housekeeping staff were doing a great job in making sure the facility was clean during the construction. The allegation, staff are not ensuring the facility is free of dust is unsubstantiated.

The allegation, staff did not ensure residents room are locked is unsubstantiated. LPA and the maintenance staff member checked the resident's door that was reported not able to be locked. At 2:00 pm, LPA observed the maintenance staff worker was able to unlock the door with the master key and able to unlock the resident's door with the resident's key. LPA and the maintenance staff member checked eight rooms from 2:15 until 3:00 pm using both the master key and housekeeping keys and there were no issues. LPA also interviewed twelve residents who stated are able to lock rooms using their own key.

Exit interview conducted and a copy of the signed report was given to the Business Office Manager.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

LIC9099 (FAS) - (06/04)

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