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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 02/13/2023
Date Signed: 02/13/2023 12:09:18 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, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:MINDY MENDOZA-PERRYFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: DATE:
02/13/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mindy Mendoza-PerryTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
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9
Staff are not following COVID-19 protocols
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit with Administrator at 11:00 am. LPA stated the purpose of the visit was regarding the allegation, staff are not following COVID 19 protocols. LPA Spaeth interviewed reporting party on 12/14/2022 and asked for clarification regarding the allegation. The reporting party stated there are no issues and stated did not mention there were issues regarding COVID 19 protocols. Reporting party stated staff were properly wearing masks and following the COVID guidelines. Also, LPA interviewed twelve (12) residents on 1/09/2023 who stated staff were following the COVID-19 guidelines and residents did not have any issues regarding this allegation. Therefore the allegation is unsubstantiated.

Exit interview conducted and a copy of the signed 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: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
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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