<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 08/06/2025
Date Signed: 08/06/2025 10:51:16 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
07/11/2025 and conducted by Evaluator Angelica Segovia
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250711120809
FACILITY NAME:HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:KATHERINE ALEMANFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 104DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:KATHERINE ALEMAN- Executive DirectorTIME COMPLETED:
11:10 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure facility was kept clean, safe and sanitary.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/06/2025 at approximately 9:45 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Executive Director, Katherine Aleman, and stated the reason for their visit was to deliver the findings of the complaint.


To investigate the allegation(s), on 7/19/2025 at approximately 10:00 AM, LPA conducted a physical plant tour. From 11:30 AM to 2:30 PM, LPA conducted interviews with nine (9) residents (R1-R9), two (2) staff members (S1-S2) and conducted record reviews.


(Continue to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20250711120809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE
FACILITY NUMBER: 197609720
VISIT DATE: 08/06/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff did not ensure facility was kept clean, safe and sanitary. It was alleged that the facility’s laundry room was not kept clean and staff were neglecting their residents from maintaining safe and sanitary conditions. To investigate the allegation(s), LPA conducted interviews with nine (9) residents and two (2) staff members. LPA’s interview with all residents confirmed that staff do not neglect them nor have they witnessed other residents to be neglected. During LPA’s interview with residents, LPA did not observe residents’ rooms to emit foul odors. LPA observed residents throughout various areas of the facility such as in the seating area, the dining area and activity center. LPA observed the residents to appear to be in good health and interacting with their peers.

During a physical plant tour of the laundry rooms and an interview with S1 revealed that the laundry rooms are cleaned weekly but there have been a few residents who have made it a habit not to throw their trash away properly. LPA’s interview with S2 revealed that the laundry rooms are cleaned throughout each shift, “…Morning, afternoon, and night shift”. However, during LPA’s physical plant tour, LPA observed two (2) out of the four (4) laundry rooms not to be clean. LPA observed both laundry rooms located on the second floor, which are accessible to Residents, had unsecured waste bin lids. Additionally, one (1) of the two (2) laundry rooms were observed to have Personal Protective Equipment (PPE) gloves left unsecured on the floor, an uncovered waste container, canned alcoholic beverages left on the floor, and bagged garbage placed outside of the designated waste containers.

Based on LPA’s observations, the facility did not maintain two (2) out of the four (4) laundry rooms clean, safe, and in sanitary condition, therefore the allegation is SUBSTANTIATED at this time.

Citation issued, please refer to 9099-D.

No other immediate health and safety hazards observed during the time of the visit.

Exit interview conducted, Appeal Rights given, and a copy of this report was provided to the Executive Director.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250711120809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE
FACILITY NUMBER: 197609720
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2025
Section Cited
CCR
87303(a)(1)
1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary...at all times… Maintenance shall include… well-being of residents…(1)... laundry…areas shall be maintained in a clean, sanitary…condition.
This requirement was not met by:
1
2
3
4
5
6
7
The Executive Director will email LPA Segovia photos of the new trash bins with secured lids in each laundry room, a statement of communication with residents/staff regarding proper disposal of trash and agreement of laundry rooms being checked on twice a day for cleanliness and upkeep.
8
9
10
11
12
13
14
Based on LPA’s observations 2 out of the 4 laundry rooms were not kept clean or in sanitary conditions which poses a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3