197609720-10-4-2023-31-AS-TAGD-CWRSDC-20231019134654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 12/01/2021
Date Signed: 10/04/2023 11:23:07 AM

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
01/19/2021 and conducted by Evaluator Melissa Spaeth

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210119140608

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: 80	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Autumn Rodriguez and Andrea Gutierrez		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are not following State of California COVID-19 guidelines and are endangering the health of residents

INVESTIGATION FINDINGS:

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This is an amended copy of the report previously issued on 12/01/2021 and 01/09/2023. After review of this complaint, it was determined full names of interviewees were used in lieu of confidential identifiers. The findings for this complaint remain the same.

LPA Spaeth conducted an unannounced complaint visit to the facility and was greeted by Autumn Rodriguez, Executive Director. LPA Spaeth explained the purpose of the visit was to investigate a complaint which states staff are not following State of California COVID-19 guidelines and are endangering the health of residents.
It’s being alleged that a staff member worked at the facility after receiving a positive COVID test, staff members are congregating in a break area not wearing masks, the facility is hosting a “car and craft show, and covid testing are being delayed. During interviews, LPA interviewed a staff member who confirmed a positive staff member did not work while quarantined for COVID. LPA Spaeth interviewed Executive Director and S2 from 11:15 am until 11:45 am. At 11:50 am, staff member S2 and LPA observed the staff break

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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-20210119140608

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: 12/01/2021

NARRATIVE

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room. LPA observed the door to the room was shut. Upon entering the break room, , LPA observed two staff members eating lunch The room is spacious allowing for social distancing when needed. S2 escorted LPA to the window where outdoor seating is available for staff. S2 stated staff also use the outdoor area for breaks. At 12:00 pm, LPA interviewed S3 and concluded the interview at 12:25 pm. LPA Spaeth interviewed S1 from 12:35 pm until 12:55 pm and interviewed staff member S4 from 12:55 pm until 1:05 pm. LPA observed a Facebook posting at 1:15 pm which stated the facility would have held a car and craft show at the facility on February 6, 2021. However, the show was cancelled. Two staff members confirmed the car and craft show did not occur. LPA observed the testing records which indicated the tests were received within two to four days.

During interviews with residents, LPA conducted interviews from 10:15am to 4:45pm. No resident confirmed the allegation to be true. Residents observed staff always wearing masks and state staff have been responsible and have been wearing masks without any incident.

Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted, and a copy of the report was emailed to the facility.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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